Justification of CBCT and Guidelines for Clinical Use

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1 Justification of CBCT and Guidelines for Clinical Use Dr. Vivian E. Rushton

2 Clinical Guidelines Systematically developed statements to assist practitioner and patient decisions about appropriate healthcare for specific clinical circumstances (Field and Lohr 1990)

3 Systematic Review Process Structured process involving several steps: 1. Well formulated question 2. Comprehensive data search 3. Unbiased selection and abstraction process 4. Validity assessment of papers 5. Synthesis of data

4 Evidence Based Practice Further research required Implement findings Appraise for validity and usefulness systematic reviews Clinical decision Find evidence Evaluate performance Information need Formulate answerable question 4

5 Why are guidelines needed? A useful investigation is one in which the result positive or negative will inform clinical management and/or add confidence to the clinician s diagnosis

6 Justification Relates to Council Directive 97/43/Euratom Scope and definition of justification greatly expanded in the Directive 97/43/ Euratom of 3rd June 1997 Justification forms the basis of all EU documents relating to the use of ionising radiation

7 It is probable that there are significant justification problems in radiological practice in the developing world. In the West, recent studies indicate that > 20% of examinations may not be appropriate; this can be as high as 45% in special cases, and up to 75% for specific techniques

8 JUSTIFICATION All CBCT examinations must be justified on an All individual exposures basis by demonstrating must that be justified and the benefits to the patients outweigh the potential recorded risks. CBCT examinations should potentially add new information to aid the Justification patient s managements requires that the patient ED BP receives a net benefit from the x-ray examination Radiography of patients prior to clinical CBCT should not be selected unless a examination can NEVER be justified history and clinical examination have been performed. Routine imaging is unacceptable practice ED BP

9 Why Referral Criteria? CBCT equipment was being used in clinical practice without the benefit of referral criteria initially Local referral criteria were adopted in When referring a patient for a CBCT some hospitals examination, the referring dentist must supply sufficient clinical information (results of a Concerns history and expressed examination) to allow regarding the CBCT the use of Practitioner to perform the Justification CBCT especially in children process ED BP Priority given to derive referral criteria

10 Consensus Guidelines of the European Academy of Dental and Maxillofacial Radiology Section 3.3: The Basic Principles

12 AIMS and OBJECTIVES To collect and analyse relevant published material and any published guidelines relating to cone beam computed tomography To develop evidence based guidelines on the use of CBCT in dentistry including referral criteria, quality assurance guidelines and optimisation strategies

13 Methodology Methodology was previously detailed in the Interim Guidelines Published guidelines on CBCT obtained for France, Denmark, Germany and Norway and reviewed by the Panel

14 Grading Systems used for levels of Grade A B C D GP evidence At least one meta analysis, systematic review, or RCT rated as 1++, and directly applicable to the target population; or a systematic review of RCTs or a body of evidence consisting principally of studies rated as 1+, directly applicable to the target population and demonstrating overall consistency of results A body of evidence including studies rated as 2++, directly applicable to the target population, and demonstrating overall consistency of results; or extrapolated evidence from studies rated as 1++ or 1+ A body of evidence including studies rated as 2++, directly applicable to the target population, and demonstrating overall consistency of results; or extrapolated evidence from studies rated as 2++ Evidence level 3 or 4; or extrapolated evidence from studies rated as 2+ Good practice ( based on clinical expertise of the guideline group)

Safety and Efficacy of a New and Emerging Dental X-ray Modality 2008-2011.

guidelines for sound dealing and necessary scientifically with justification, based clinical

16 Safety and Efficacy of a New and Emerging Dental X-ray Modality to is the use acquisition the information of the to develop key information evidencebased guidelines for sound dealing and necessary scientifically with justification, based clinical optimisation use of and dental referral Cone criteria Beam... Computed for users of Tomography CBCT (CBCT)

17 Diagnostic Accuracy Hierarchical model proposed by Fryback and Thornbury, 1991 Technical efficacy Diagnostic accuracy efficacy Diagnostic thinking efficacy Therapeutic efficacy Patient outcome efficacy Societal efficacy

Clinical applications Restoring the dentition Caries detection Periodontology Periapical pathosis and endodontics Surgical applications

18 Clinical applications Restoring the dentition Caries detection Periodontology Periapical pathosis and endodontics Surgical applications Exodontia Implant Dentistry Bony Pathoses Trauma Orthognathic Surgery The developing jaws and dentition Impacted teeth Cleft palate Routine orthodontics

19 Recommendations of the Systematic Literature Review

20 Restoring the dentition Caries detection Periodontology Periapical pathosis and endodontics Implantology

In five in vitro studies with ROC analysis, no differences between CBCT and intraoral radiography Two other studies (Haiter-Neto et al.

21 Caries detection: Approximal Studies included used a valid reference (index) standard Seven studies of proximal caries: Tsuchida et al.,2007; Haiter-Neto et al.,2007; Young et al.,2009; Qu et al., 2010; Kayipmaz et al., 2010; Senel et al., 2010; Zhang et al., 2011). In five in vitro studies with ROC analysis, no differences between CBCT and intraoral radiography Two other studies (Haiter-Neto et al.,2008; Young et al.,2009) found higher sensitivity for detection of proximal dentine caries with small volume CBCT Images from Tsuchida et al (2007) Oral Surg 2007; 104:

22 Caries detection: Occlusal Three studies: Haiter-Neto et al.,2008; Young et al., 2009;Kayipmaz et al., Each showed increased sensitivity for occlusal caries compared with conventional radiography Some loss of specificity (Young et al., 2009) For occlusal caries, depth correlates better than intraoral radiography in vitro. In vivo, metallic restorations will degrade image and reduce diagnostic accuracy

23 Caries detection CBCT is not indicated as a method of caries detection and diagnosis B

24 Periodontal diagnosis Limited literature relating to periodontal assessment. CBCT is not indicated as a standard method of imaging periodontal bone support C Two accuracy studies identified (Mol &Balasundaram, 2008 and Noujeim et al., 2009) CBCT may be indicated in selected CBCT cases was superior of intra-bony to intraoral defects and radiography furcation lesions, for crater where and furcation clinical and defect imaging conventional radiographic (Vandenberghe examinations et do al 2008; not provide Ito et al the 2001; information Kasaj & needed Willershausen for management 2007; Naitoh, 2006) C

25 Periodontal diagnosis Where CBCT images include the teeth, care should be taken to check for periodontal bone levels when performing a clinical evaluation (report) GP

following apiceptomy than conventional imaging Four studies eligible for the systematic

26 Periapical diagnosis Properly validated in vivo studies impossible due to lack of a true reference standard More recent studies have shown that CBCT identifies more periapical defects following apiceptomy than conventional imaging Four studies eligible for the systematic review: Stavropoulos and Wenzel, 2007; de Paula Silva et al., 2009; Patel et al., 2009; Soğur et al. 2009).

performing a clinical evaluation ( report) GP CBCT may be indicated for periapical assessment, in selected

27 Periapical diagnosis CBCT is not indicated as a standard method for identification of periapical inflammatory pathosis GP Where CBCT images include the teeth, care should be taken to check for periapical disease when performing a clinical evaluation ( report) GP CBCT may be indicated for periapical assessment, in selected cases, when conventional radiographs give a negative finding when there are contradictory positive clinical signs and symptoms C

28 Endodontics

29 Endodontics No study satisfied inclusion criteria for systematic review One study (Blattner et al., 2010) provided data to allow it to be formally reviewed finding that sensitivity for MB2 canals was 77% Due to a paucity of information regarding diagnostic accuracy, the Panel could not support its general use for this purpose CBCT may be considered for selected cases where intraoral radiographs provide information on root canal anatomy that is equivocal or inadequate for planning treatment, most probably in multi rooted teeth C

30 CBCT is not indicated as a standard method for demonstration of root canal anatomy GP

Surgical Endodontic Treatment Limited literature Use of CBCT as part of planning and performing surgical procedures seems capable of justification on empirical grounds CBCT may be indicated

31 Surgical Endodontic Treatment Limited literature Use of CBCT as part of planning and performing surgical procedures seems capable of justification on empirical grounds CBCT may be indicated for selected cases when planning surgical endodontic procedures. The decision should be based upon potential complicating factors, such as the proximity of important anatomical structures GP

Internal and External Root Resorption CBCT may be indicated in selected cases of suspected, or established, inflammatory external root resorption or internal resorption, where three-dimensional

32 Internal and External Root Resorption CBCT may be indicated in selected cases of suspected, or established, inflammatory external root resorption or internal resorption, where three-dimensional information is likely to alter the management or prognosis of the tooth Four research studies included in systematic review (Liedke et al., 2009; Patel et al., 2009; Kamboroglu D & Kurson 2010; Durack et al., 2009) Majority of studies laboratory based Difficulties with unpredictability of the CBCT may be indicated for selected cases, condition where and the endodontic limitation treatment of existing is complicated literature by being concurrent laboratory factors, based such as resorption lesions, combined periodontal/endodontic lesions, perforations and atypical pulp anatomy C

33 Endodontic applications of CBCT Differentiation of pathosis from normal anatomy Relationships with important anatomical structures Aiding management of dens invaginatus and aberrant pulpal anatomy External resorption Internal resorption Lateral root perforation by a post Accessory canal identification Surgical management of fractured instrument Aiding surgical endodontic planning Reference Cotton et al, 2007 Cotton et al, 2007 John, 2008 Siraci et al, 2006 Maini et al, 2008 Cohenca et al, 2007 Walter et al, 2008 Patel et al, 2007 Patel & Dawood, 2007 Cotton et al, 2007 Young 2007 Cotton et al, 2007 Nair et al, 2007 Patel & Dawood, 2007 Tsurumachi et al, 2007 Patel et al, 2007 Patel & Dawood, 2007

34 Dental Trauma Seven publications included in systemic review High resolution (Hassan et CBCT al. 2009; is Iikubo indicated in the et al. 2009; assessment Wenzel et al., of 2009; dental Hassan trauma et al. (suspected root 2010; Kamboroglu et al., 2010; Ozer 2010; fracture) in selected cases, where Varshozas et al., 2010) conventional radiographs provide inadequate information for treatment planning Low resolution scans (0.3mm B or larger voxel size) may not offer diagnostic advantage (Wenzel et al., 2009; Hassan et al. 2010; Kamboroglu et al., 2010; Melo et al.,2010)

35 Application of CBCT for dento-alveolar trauma Reference Root fractures Luxation injuries Avulsion Root resorption as a post-trauma complication Terakado et al 2000 Cohenca et al 2007a Cotton et al 2007 Nair et al, 2007 Patel & Dawood 2007 Melo et al Cohenca et al 2007a Patel et al 2007 Walter & Krastl 2008 Cohenca et al 2007b Walter et al, 2008

Large number of studies Conclusions are that CBCT offers advantages for the surgeon in showing the anatomical position of mandibular third molars were there is a close relationship to the ID canal.

36 Large number of studies Conclusions are that CBCT offers advantages for the surgeon in showing the anatomical position of mandibular third molars were there is a close relationship to the ID canal. Exodontia Where conventional radiographs suggest a close between a mandibular third molar and the inferior dental canal, and when a decision to perform surgical removal has been made, CBCT is indicated B

37 CBCT may be indicated for pre-surgical assessment of an unerupted tooth in selected cases where conventional radiographs fail to provide the information required GP

38 Implantology Main driver for development of CBCT Conventional (medical) CT has been the main method Radiation dose advantage of CBCT Cone beam Conventional CT Image quality advantages

39 Implants: Special indications for crosssectional imaging Maxilla Mandible Single tooth a. incisive canal b. descent of maxillary sinus c. clinical doubt about shape of alveolar ridge a. descent of maxillary sinus b. clinical doubt about shape of alveolar ridge Partially dentate Edentulous a. descent of maxillary sinus b. clinical doubt about shape of alveolar ridge Single a. clinical doubt about position of mandibular canal tooth b. clinical doubt about shape of alveolar ridge Partially dentate a. clinical doubt about position of mandibular canal or mental foramen b. clinical doubt about shape of alveolar ridge Edentulous a. severe resorption b. clinical doubt about shape of alveolar ridge c. clinical doubt about position of mandibular canal if posterior implants are to be placed *modified from Harris et al.2002 Harris et al. European Association of Osseointegration guidelines for the use of diagnostic imaging in implant dentistry. Clin Oral Implants Res 2002; 13:

Implant Dentistry No studies included for systematic review existing cross- sectional techniques where on diagnostic accuracy Studies on geometric accuracy D supported the use of CBCT for linear

40 Implant Dentistry No studies included for systematic review existing cross- sectional techniques where on diagnostic accuracy Studies on geometric accuracy D supported the use of CBCT for linear measurements Better For subjective cross-sectional image imaging quality prior for to implant important placement, structures the advantage compared of CBCT with MSCT with Several studies reviewed the accuracy of implant region of interest is a localised part of the placement using surgical guides reporting that, within jaws, as a similar sized field of view can be specified limits of error, used CBCT is an effective method of providing the data for GP the manufacture of surgical guides CBCT is indicated for cross-sectional imaging prior to implant placement as an alternative to the radiation dose is shown to be lower adjustable fields of view, compared with conventional CT, becomes greater where the

41 Bony Pathosis Where it is likely that evaluation of soft tissues will be required as part of the patient s radiological assessment, the appropriate initial Four imaging studies should were be conventional reviewed multislice by the Panel CT or MR rather than CBCT (Hendrikx et al., 2010; Momin et al., 2009; Rosenberg et al., 2010; Simon et al., BP 2006) Panel concluded that in cases of oral malignancy, other cross-sectional imaging (MSCT, MR) would be performed first as part of a diagnostic work-up. CBCT may be indicated for evaluation of bony invasion of the jaws by oral carcinoma when the initial imaging modality used for diagnosis and staging (MR or multislice CT) does not provide satisfactory information D

$between CT and CBCT For maxillofacial fracture assessment, where cross-sectional imaging is judged to be necessary, CBCT may be indicated as an alternative imaging modality to conventional CT where$

42 Maxillofacial Trauma Confined to hospital practice Currently imaged by plain radiography and/or conventional CT One study identified for systematic review (Sirin et al 2010) reporting no differences between CT and CBCT For maxillofacial fracture assessment, where cross-sectional imaging is judged to be necessary, CBCT may be indicated as an alternative imaging modality to conventional CT where radiation dose is Several case studies/case series confirmed these findings for trauma in the facial region shown to be lower and soft tissue detail is not required D

43 Impacted teeth: canines

tooth) where the current imaging method of choice is

44 For the localised assessment of an impacted tooth (including consideration of resorption of an adjacent tooth) where the current imaging method of choice is MSCT, CBCT may be preferred because of reduced radiation dose GP

45 External resorption in relation to unerupted teeth CBCT may be indicated for the localised assessment of an impacted tooth (including consideration of resorption of an adjacent tooth) where the current imaging method of choice is conventional dental radiography and when the information cannot be obtained adequately by lower dose conventional (traditional) radiography C

46 External resorption in relation to unerupted teeth For the localised assessment of an impacted tooth (including consideration of resorption of an adjacent tooth), the smallest volume size compatible with the situation should be selected because of the reduced radiation dose. The use of CBCT units offering only large volumes (craniofacial CBCT) requires very careful justification and is generally discouraged GP BP

47 Application of CBCT for orthodontics Cleft palate assessment Tooth position and localisation Resorption related to impacted teeth Measuring bone dimensions for mini-implant placement Reference Müssig et al 2005 Hamada et al 2005 Wörtche et al 2006 Chaushu et al, 2004 Kau et al 2005 Nakajima et al 2005 Walker et al 2005 Liu et al 2007 Liu et al 2008 Mussig et al 2005 Kau et al 2005 Liu et al 2008 Gracco et al 2006 King et al 2006 Gracco et al 2007 Gracco et al 2008 Kim et al 2007

48 Application of CBCT for orthodontics For rapid maxillary expansion 3-dimensional cephalometry Surface imaging integration Reference King et al 2007 Rungcharassaeng et al 2007 Garrett et al 2008 Baumrind et al 2003 Swennen & Scutyser 2006 Lane & Harrell 2008 Airway assessment Age assessment Investigation of orthodontic-associated paraesthesia Maal et al 2008 Aboudara et al, 2003 Kau et al 2005 Ogawa et al 2007 Shi et al 2007 Erickson et al 2003

49 Cleft palate Where the current imaging method of Use of CBCT in this condition choice for the assessment of cleft palate has is been MSCT, CBCT the subject may be preferred of where radiation dose is lower. The smallest several volume non-systematic size compatible with the situation reviews should be selected because of reduced radiation dose C 3 dimensional imaging used to determine volume of bone needed for grafting and adequacy of bone fill after surgery

Temporary Orthodontic Anchorage Using mini-implants Several studies conducted

(TADs) CBCT is not normally indicated for CBCT has been planning shown the to

order to identify optimal position anchorage devices in orthodontics GP

50 Temporary Orthodontic Anchorage Using mini-implants Several studies conducted to measure available bone thickness for placing temporary anchorage devices (TADs) CBCT is not normally indicated for CBCT has been planning shown the to be placement used by of some temporary as a clinical tool prior to placement in order to identify optimal position anchorage devices in orthodontics GP Research found that 3-dimentional imaging was only needed in rare cases (Jung et al., 2010)

51 Generalised application of CBCT for the Large volume CBCT should not be used routinely developing for orthodontic diagnosis dentition Simple algorithms are available (Isaacson et al; 2008 ) Algorithms for selecting radiographs for orthodontic patients Research are also is available needed to define (European robust Commission guidance on clinical selection for large 2004) No evidence quantification to support of benefit the to patient routine outcome use of large volume GP CBCT at any stage of orthodontic treatment GP volume CBCT in orthodontics, based upon For complex cases of skeletal abnormality, particularly those requiring combined orthodontic/surgical management, large volume CBCT may be justified in planning the definitive procedure, particularly where MSCT is the current imaging method of choice GP

52 Cleft palate Where the current imaging method of choice for the assessment of cleft palate is MSCT, CBCT may be preferred where radiation dose is lower. The smallest volume size compatible with the situation should be selected because of reduced radiation dose C

53 Orthognathic Surgery The patients likely to be candidates for orthognathic surgery (with significant facial deformity) are more likely to benefit from cross sectional imaging Papers included reviews: (Caloss et al., 2007; Edwards 2010; Popat et al., 2010; Swennen et al., 2009) CBCT is indicated, in selected cases, where only bone information is required, for obtaining three dimensional datasets of the craniofacial skeleton C

54 Temporomandibular Joint The majority of patients with signs and symptoms are suffering from myofascial pain/dysfunction or internal disc derangements. Appropriate imaging is magnetic resonance imaging. For bony pathology, consider whether the identification of bony pathology will alter management of the patient Four diagnostic accuracy papers with valid reference standards (Honda et al., 2006; Hintze et al., 2007; Honey et al. 2007; Marques et al.,2010).

Temporomandibular Joint CBCT images provided similar diagnostic accuracy to conventional CBCT and greater accuracy Where than the existing panoramic imaging radiography modality for and linear

55 Temporomandibular Joint CBCT images provided similar diagnostic accuracy to conventional CBCT and greater accuracy Where than the existing panoramic imaging radiography modality for and linear examination tomography of the in TMJ the is detection conventional of condylar cortical CT, erosion CBCT is indicated as an alternative where radiation dose is shown to be No differences noted lower in diagnostic accuracy between CBCT and B conventional tomograms The Research Diagnostic Criteria highlight that imaging of the TMJ is not required for a diagnosis (Petersson 2010) No clear evidence as to when TMD patients should be imaged

57 Acknowledgement: The research leading to these results has received funding from the European Atomic Energy Community s Seventh Framework programme FP7/ under grant agreement no (: Safety and Efficacy of a New and Emerging Dental X-ray Modality).

SEDENTEXCT: Guidelines and evidence-based use of CBCT

SEDENTEXCT: Guidelines and evidence-based use of CBCT : Guidelines and evidence-based use of CBCT Keith Horner John Dalton Rutherford Bragg UK largest single-site University 34,000 students University Dental Hospital of Manchester 90,000 patients attend