justification of cbct and guidelines for clinical usesedentexct.eu/system/files/dr rushton.pdf ·...

Workshop on dental Cone Beam CTSEDENTEXCT

Justification of CBCT

and Guidelines for

Clinical Use

Dr. Vivian E. Rushton


Clinical Guidelines

„Systematically developed

statements to assist practitioner

and patient decisions about

appropriate healthcare for

specific clinical circumstances‟

(Field and Lohr 1990)


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


Evidence Based Practice

4

Implement findings

Formulate

answerable

question

Find evidence

Evaluate

performance

Appraise

for validity

and

usefulness

Clinical

decision

Information

need

Further research

required

systematic reviews


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”


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


‘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’


JUSTIFICATION

• All exposures must be justified and recorded

• Justification requires that the patient receives a net benefit from the x-ray examination

• Radiography of patients prior to clinical examination can NEVER be justified

All CBCT examinations must be justified on an individual basis by demonstrating that the benefits to the patients outweigh the

potential risks. CBCT examinations should potentially add new information to aid the

patient‟s managements

ED BP

CBCT should not be selected unless a history and clinical examination have been

performed. „Routine‟ imaging is unacceptable practice

ED BP


Why Referral Criteria?

• CBCT equipment was being used in

clinical practice without the benefit of

referral criteria initially

• Local referral criteria were adopted in

some hospitals

• Concerns expressed regarding the use of

CBCT especially in children

• Priority given to derive referral criteria

When referring a patient for a CBCT examination, the referring dentist must supply

sufficient clinical information (results of a history and examination) to allow the CBCT

Practitioner to perform the Justification process ED BP


Consensus Guidelines of the European Academy of

Dental and Maxillofacial Radiology

Section 3.3: The Basic Principles


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


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


Grading Systems used for levels of

evidence

Grade

A 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

B 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+

C 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++

D Evidence level 3 or 4; or extrapolated evidence from studies rated as

2+

GP Good practice ( based on clinical expertise of the guideline group)


Safety and Efficacy of a New and

Emerging Dental X-ray Modality

www.sedentexct.eu

2008-2011

.... is the acquisition of

the key information

necessary for sound and

scientifically based

clinical use of dental

Cone Beam Computed

Tomography (CBCT)

.....to use the information

to develop evidence-

based guidelines dealing

with justification,

optimisation and referral

criteria ....... for users of

CBCT

http://www.sedentexct.eu/


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

•Exodontia

•Implant Dentistry

•Bony Pathoses

•Trauma

•Orthognathic Surgery

The developing jaws and

dentition•Impacted teeth

•Cleft palate

•“Routine” orthodontics


Recommendations of the

Systematic Literature Review


Restoring the dentition

• Caries detection

•Periodontology

•Periapical pathosis

and endodontics

•Implantology


Images from Tsuchida et al (2007) Oral

Surg 2007; 104:412-416

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


Caries detection:

Occlusal

Three studies: Haiter-Neto et al.,2008; Young et

al., 2009;Kayipmaz et al., 2010.

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


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

B

Caries detection


Periodontal diagnosis

Limited literature relating to

periodontal assessment.

Two accuracy studies

identified (Mol &Balasundaram, 2008

and Noujeim et al., 2009)

CBCT was superior to intraoral

radiography for crater and furcation

defect imaging

(Vandenberghe et al 2008; Ito et al

2001; Kasaj & Willershausen 2007;

Naitoh, 2006)

CBCT may be indicated in selected cases of intra-bony defects and

furcation lesions, where clinical and conventional radiographic

examinations do not provide the information needed for management

C

CBCT is not indicated as a standard method of imaging periodontal bone

support

C


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


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).


Periapical diagnosis

CBCT is not indicated as a standard method for identification of periapical inflammatory pathosis

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

Where CBCT images include the teeth , care should be taken to check for periapical disease when

performing a clinical evaluation ( report)

GP


Endodontics


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


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 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

Four research studies included in

systematic review(Liedke et al., 2009; Patel et al., 2009; Kamboroglu

& Kurson 2010; Durack et al., 2009)

Majority of studies laboratory based

Difficulties with unpredictability of the

condition and the limitation of existing

literature being laboratory based

CBCT may be indicated for selected cases, where endodontic treatment is complicated by concurrent factors, such as resorption lesions, combined periodontal/endodontic

lesions, perforations and atypical pulp anatomy

C

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

D


Endodontic applications of CBCT Reference

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

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


Tsurumachi et al, 2007

Patel et al, 2007



Dental Trauma

Seven publications included in

systemic review (Hassan et al. 2009; Iikubo

et al. 2009; Wenzel et al., 2009; Hassan et al.

2010; Kamboroglu et al., 2010; Ozer 2010;

Varshozas et al., 2010)

„Low‟ resolution scans (0.3mm 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)

High resolution CBCT is indicated in the assessment of dental trauma (suspected root

fracture) in selected cases , where conventional radiographs provide inadequate

information for treatment planning

B


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. 2010

Cohenca et al 2007a

Patel et al 2007

Walter & Krastl 2008

Cohenca et al 2007b

Walter et al, 2008


Exodontia

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.

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


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


Implantology

Main driver for

development of CBCT

Conventional (medical) CT

has been the main method

Radiation dose

advantage of CBCT

Image quality

advantages

Cone beam Conventional CT


Implants: Special indications for cross-

sectional imaging

Single tooth

a. incisive canal b. descent of maxillary sinus c. clinical doubt about shape of alveolar ridge

Partially dentate

a. descent of maxillary sinus b. clinical doubt about shape of alveolar ridge

Maxilla

Edentulous

a. descent of maxillary sinus b. clinical doubt about shape of alveolar ridge

Single tooth

a. clinical doubt about position of mandibular canal 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

Mandible

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

Harris et al. European Association of Osseointegration guidelines for the use of diagnostic

imaging in implant dentistry. Clin Oral Implants Res 2002; 13: 566-570.

*modified from Harris et al.2002


Implant Dentistry

No studies included for systematic review

on diagnostic accuracy

Studies on geometric accuracy supported

the use of CBCT for linear measurements

Better subjective image quality for

important structures compared with MSCT

Several studies reviewed the accuracy of implant

placement using surgical guides reporting that, within

specified limits of error, CBCT is an effective method of

providing the data for the manufacture of surgical

guides

CBCT is indicated for cross-sectional imaging prior to implant placement as an alternative to

existing cross- sectional techniques where the radiation dose is shown to be lower

D

For cross-sectional imaging prior to implant placement, the advantage of CBCT with adjustable fields of view, compared with

conventional CT, becomes greater where the region of interest is a localised part of the

jaws, as a similar sized field of view can be used

GP


Bony Pathosis

Four studies were reviewed by the Panel

(Hendrikx et al., 2010; Momin et al., 2009; Rosenberg

et al., 2010; Simon et al., 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.

Where it is likely that evaluation of soft tissues will be required as part of the patient‟s

radiological assessment, the appropriate initial imaging should be conventional multislice CT

or MR rather than CBCT

BP

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


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

Several case studies/case series

confirmed these findings for trauma

in the facial region

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

shown to be lower and soft tissue detail is not required

D


Impacted

teeth: canines


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


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


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


Application of CBCT for orthodontics Reference

Cleft palate assessment

Tooth position and localisation

Resorption related to impacted teeth

Measuring bone dimensions for mini-implant

placement

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


Application of CBCT for orthodontics Reference

For rapid maxillary expansion

3-dimensional cephalometry

Surface imaging integration

Airway assessment

Age assessment

Investigation of orthodontic-associated

paraesthesia

King et al 2007

Rungcharassaeng et al 2007

Garrett et al 2008

Baumrind et al 2003

Swennen & Scutyser 2006

Lane & Harrell 2008

Maal et al 2008

Aboudara et al, 2003

Kau et al 2005

Ogawa et al 2007

Shi et al 2007

Erickson et al 2003


Cleft palate

Use of CBCT in this condition

has been the subject of

several non-systematic

reviews

3 dimensional imaging used

to determine volume of bone

needed for grafting and

adequacy of bone fill after

surgery

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


Temporary Orthodontic Anchorage Using

„mini-implants‟

Several studies conducted to measure available bone

thickness for placing temporary anchorage devices

(TADs)

CBCT has been shown to be used by some as a clinical

tool prior to placement in order to identify optimal position

Research found that 3-dimentional imaging was only

needed in rare cases (Jung et al., 2010)

CBCT is not normally indicated for planning the placement of temporary anchorage devices in orthodontics

GP


Generalised application of CBCT for the

developing dentition

• Simple algorithms are available (Isaacson et al; 2008 )

• Algorithms for selecting radiographs for orthodontic

patients are also available (European Commission

2004)

• No evidence to support the routine use of large volume

CBCT at any stage of orthodontic treatment

Large volume CBCT should not be used routinely for orthodontic diagnosis

GP

Research is needed to define robust guidance on clinical selection for large

volume CBCT in orthodontics, based upon quantification of benefit to patient outcome

GP

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


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


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


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 than panoramic radiography and

linear tomography in the detection of condylar

cortical erosion

• No differences noted in diagnostic accuracy

between CBCT and 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

Where the existing imaging modality for examination of the TMJ is conventional CT, CBCT is indicated as an alternative

where radiation dose is shown to be lower

B


Acknowledgement: The research leading to these

results has received funding from the European

Atomic Energy Community‟s Seventh Framework

programme FP7/ 2007-2011 under grant agreement

no. 212246 (SEDENTEXCT: Safety and Efficacy of a

New and Emerging Dental X-ray Modality).

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