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science & practice22 Show Preview IDS Cologne 2015 implant continuing education with an excessof25,000activemembers,pub- lished a consensus report on CBCT in itsjournalImplantDentistryinAprilof 2012. In the article, authored by many leaders in the dental implant field, the ICOI states: “The literature supports theuseofCBCTindentalimplanttreat- ment planning particularly in regards to linear measurements, 3-D evalua- tion of alveolar ridge topography, proximity to vital anatomic struc- tures, and fabrication of surgical guides.” The ICOI reminds the dentist that use of CBCT must be justified in eachcaseandshouldbeconsideredas an imaging alternative where conven- tional radiographs may not provide sufficient anatomic truth. Literature discussing the application of CBCT in implant dentistry is ubiquitous and comprises the lion’s share of research in applying CBCT technology to den- tistry. The vast majority of post-doc- toralresidenciesinvolvedindentalim- plant patient care and all private den- tal implant training courses in the US incorporate CBCT in their dental im- plant education curriculum. Many professional organisations in dentistry for general dentists and specialists have weighed in on CBCT by providing recommendations, guidelines,andapositionpaper.While these guidelines are beneficial in es- tablishing a society or specialty’s position on CBCT, they are not man- dates. Recommendations, guidelines, CE programmes, and position papers are used by professionals to influence the practice of their discipline. As the practiceofthedisciplinechangesinre- sponse to many factors including, but not limited to court verdicts, expert testimony, literature support, profes- sional guidelines, cost of the technol- ogy, and reimbursement by third party payers; the recommendations, guidelines, and position papers may facilitate the evolution of CBCT into a standardofcare.Thus,in2014thepro- fessional organisations that comprise dentistry may not formally declare CBCT is the standard of care for every patient, but these organisations do recognise the influence CBCT is hav- ing on the profession. Educational Institutional Participation For a technology to be considered a standard of care, those in the profes- sion must be educated in its applica- tion in patient care. In US, 56 of the 57 dental schools (98 %) have CBCT avail- able for patient care for pre-doctoral students. Forty-seven (84 %) incorpo- rate 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 den- tistry (AEGD) programmes were sur- veyed regarding use of CBCT by their residents. Eighty-two programme di- rectorsrespondedtothesurvey.Ofthe 82 respondents, 56 (68 %) of program directors (PDs) responded affirma- tivelywhenaskedifCBCTwasusedin patientcarebytheirresidents.Theau- thoralsosurveyed102PDsinoraland maxillofacial programs in the US. Fifty-four PDs responded. Of the 54 PDs responding 47 (87 %) affirma- tively when asked if CBCT is used in patient care by their residents. In a phone survey of endodontic residen- cies, 44 of 47 PDs indicated their resi- dents use CBCT in patient care. All sevenADA-approvedoralandmaxillo- facial radiology programmes use CBCT in patient care. Additionally, all 51 periodontal residency PDs indi- cated that their residents employ CBCTtechnologyinpatientcare.Inor- thodontics, 83 % of US-based ortho- dontic programmes use CBCT in pa- tient care. Cost and Availability The cost of CBCT machines today range from US$150,000 to US$250,000withyearlymaintenance fees in the US$8,000 to US$20,000 range. As with any emerging technol- ogy,advancescreateasecondarymar- ket 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, despite itsobviousvalueanditssuperiorityto two dimensional films. As time pro- gresses and advancement in the qual- ity and capabilities of the newest ma- chines demonstrate themselves, the slightly non-contemporary machine will represent a significant advance- ment for the dentist versus 2-D radio- graphy, while not burdening the den- tist with significant cost. This will un- doubtedly lead to an increase in the number of dental professionals utilis- ingCBCTintheirpractices.Thebottom line for most practices in regards to CBCT machines is: can I afford this for my practice? To determine affordability, the price of the machine (purchase and maintenance) must be considered against potential revenue generated by the machine. Revenue can be di- rectly from patients, insurance com- panies, or from other dentists who utilisetheCBCTmachine.Acost-effec- tive alternative to owning and operat- ingaCBCTdevicecanbetheoutsourc- ing of the study to a third party (den- tist or facility) and in-sourcing the software necessary to employ the im- ages in treatment planning and diagnosis. CBCT machines are becoming 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 ac- ceptance will increase, facilitating the incorporation of CBCT into the main- stream culture of dentistry. The in- creasing omnipresence of CBCT tech- nologywillnotsingularlymakeitstan- dard of care, but it will serve to in- crease patient awareness of the technology, which in turn will influ- ence what the public perceives as a standard of care. The insurance industry Reimbursementfrommajorinsur- ance companies and government- sponsored health care is traditionally the last to embrace (i.e. pay for) a new service such as CBCT. Although codes for medical CBCTs have been around fordecades,specificcodesforinoffice CBCTs began to materialise in 2009. Currentreimbursementratesforin-of- fice CBCTs average around US$300, provided the study is covered. By providing dentists with a CPT code, the insurance industry has vali- datedthetechnologyofCBCTandthus acknowledged its value in treatment planning and diagnosis. As time pro- gresses, insurance companies may, as they have in the past, require CBCT owner/operators to obtain a certifi- cation via the IAC or some other regu- lating entity for an owner/operator to qualify for financial reimbursement from any third party payer. Two of the major malpractice car- riers of the insurance industry (OMN- SIC and MedPro) have influenced the evolutionofCBCTasanewstandardof care by offering coverage for CBCT owner/operators commensurate with thelevelofrisktowhichtheowner/op- erators are exposed. Were CBCT stud- ies believed to be of little value or rep- resent minimal risk these leaders in the dental malpractice industry would not offer such coverage. Addi- tionally 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 recognised specialties; four (oral and maxillofa- cial surgery, endodontics, oral and maxillofacialradiology,andorthodon- tics) and the American Dental Associ- ation have produced literature to ad- dress the impact of CBCT on patient care.Oftheremainingfivespecialties, periodontics and prosthodontics could logically be appropriate groups to produce a position paper on CBCT given their members participation in dental implant treatment of patients. Paediatricdentistrymaysoonprovide a position paper once the long-term studies have been done to assess the risk versus benefits analysis with re- specttothetotaloverallradiationdose anditseffectonthepaediatricpopula- tion. The specialty of dental public health is unlikely to weigh on the mat- ter. The value CBCT has in diagnosis and treatment of patients is wide- spread and recognised by medical dis- ciplines such as plastic and recon- structive surgery, ENT, Craniofacial/ CLP surgeons, and OMFS trauma surgeons. These medical disciplines recognise the high quality three-di- mensional detail CBCT provides and assists doctors in the treatment planning and diagnosis of their pa- tients. Such widespread and multidis- ciplinaryapplicationofCBCTimaging contributestoCBCTisbecominganew standard of care. CBCT in the dental culture Many in the dental profession ac- knowledge the benefit of 3-D imaging to patients and doctors. There is little dispute that CBCT provides superior representation of the anatomy verses 2-D plain films. Quality of product ac- knowledged, at least four aspects of CBCT must work their way through the dental culture before CBCT be- comes A standard of care: cost, avail- ability,legal,andpatientexpectations. Two of these aspects (cost and avail- ability)willmorelikelythannotbede- termined by the invisible hand of the market as the Keynesians laws of sup- ply and demand move the dental in- dustry to provide the best possible service at a price patients and insur- ancecompaniesarewillingtopay.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 difficult to accurately ascertain. We know pa- tients expect our practices to be con- temporary. Buying the latest and greatest machine for your practice may not be wise if cost exceeds bene- fits both clinically and financially. As CBCT becomes widely accepted and expected by our patients due to ag- gressive marketing or clinical rele- vance, incorporating the technology into one’s practice may not be entirely necessarybutprudentasothersinthe profession who possess the technol- ogy appear to be more contemporary and advanced in their patient care. There are many questions yet to be answered definitively regarding CBCT: 1. Who is responsible (and liable) for interpreting the images? 2. Is an entire field of view interpreta- tion necessary or simply the perti- nent structures? 3. Must all images be interpreted by a board certified oral and maxillofa- cial radiologist or can the ordering doctor interpret the images? 4. Whatleveloftrainingissufficientto own and operate the machine, as well as, and interpret CBCT images? 5. What cases deserve a CBCT? 6. IfthepatientrefusesaCBCTandthe dentistbelievesaCBCTisnecessary for successful case completion, must the dentist complete the case withouttheCBCTstudyorcanhere- fuse the case without fear of legal repercussions? Lastly, as mentioned earlier, stan- dard of care is an evolving concept. Darwin stated clearly any organism (or concept in this case) which is sub- jecttothelawsofevolutionmustadapt in response to outside forces in order tosurvive.Thestandardofcareinden- tistry is adapting to CBCT as forces (le- gal, financial, clinical, and consumer) act upon the industry to account for the powerful influence CBCT has on treatment planning and diagnosis of patients. While recognising that all thatglittersisnotgold,CBCTmaysoon represent a new gold standard by which many cases will be judged. DrLeeM.Whitesidesisanoralsurgeon fromDunwoodynearAtlantaintheUS. Switzerland at its very best. www.swissdentalindustry.ch Innovation | Quality | Tradition Visit us at the IDS | Cologne, 10-14 March 2015 Swiss professional oral care 03.2 | D058 | E059 10.2 | R024 10.1 | H050 | J051 10.2 | N051 11.3 | C015 | C010 | D019 11.3 | A020 | B020 | C029 A030 | B030 | C039 04.1 | B020 11.3 | F008 | G009 10.2 | R010 | S019 10.1 | H020 | J029 10.2 | V035 11.1 | E020 10.2 | S018 11.2 | L028 | K020 | M029 | L029 04.1 | D059 10.2 | L010 | M019 11.1 | C018 | D019 10.2 | L061 04.2 | J029 | G028 04.1 | A038 10.2 | R050 11.3 | E018 | E019 11.1 | C030 10.1 | F061 11.3 | L049 AD Dr Lee M. Whitesides

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