professional education in cbct - sedentexctsedentexct.eu/system/files/prof. devlin.pdf ·...

Workshop on dental Cone Beam CTSEDENTEXCT

Hugh Devlin

Professional Education in CBCT


Where do you get information?

1. GOOGLE2. WIKIPEDIA3. JOURNALS eg DMFR

…… but we are all busy people


Recent New York Times articleRefers to a JADA issue devoted to CBCT but….

This article was paid for by the manufacturers. Journals have been accused of bias


Instruction in CBCT is not provided as part of the undergraduate dental curriculum.

In future… a requirement for CPD in reading 3-D images but there is no agreed core curriculum.

Large FOV machine – images of non dento-alveolar structure are required to be reported!


So why should I be interested in CBCT?Internet says…

1. DIAGNOSTIC QUALITY

2. SHORT SCAN TIME

3. RADIATION DOSE LESS THAN CONVENTIONAL CT

http://www.sedentexct.eu/content/provisional-guidelines-cbct-dental-and-maxillofacial-radiology�


DIAGNOSTIC QUALITY

1. 3-D image – dependant on good QA

Some measurements require a phantom… Large differences in noise between devices

• useful quantitative analysis of bone quality requires low noise and good image uniformity

HPA guidelines


Quality assurance PHANTOM – one has been developed as part of SedentexCT


Image quality assessment must be comprehensive

• As well as correct X-ray equipment function• Practical Radiation Technique • Patient dose • Image processing and viewing

No standard protocols for clinical image quality assessment for CBCT. The QA programme should entail surveys and checks


Internet said “SHORT SCAN TIME”

But shorter than what? Is it that important?

Most time spent explaining and setting up the patient for the scan


But is comparison with conventional CT scan realistic?

UK Health Protection Agency


It is not appropriate to take a CBCT examination SOLELY to reconstruct a panoramic or cephalometricradiographic view

So what EXTRA does CBCT provide that a dentist might need and want?

Implantologists and orthodontists are “targeted” by manufacturers (young patient risk!)

CBCT image is not recommended routinely in orthodontic practice. Therefore, the decision making in oral radiology is a balance between the risk assessment and the diagnostic information needed. (Silva et al, 2007)


Orthodontic Planning: insufficient training to interpret radiographs beyond the confines of their specialty but … they are obligated to read all of the film

MANUFACTURER’S WEBSITE


Where do I get help?...is it difficult?

1. German CBCT guidelines

Dentale Volumentomographie (DVT) – S1-Empfehlung.

2. Danish CBCT guidelines (2009) ..are in broad agreement

3. Norwegian guidelines

Maxillofac Rad is not a recognised specialty in some countries

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Cone Beam CT Training Courses are available

Heath Protection Agency A course on 26 July 2011 at HPA Radiation Protection Division, Centre for Radiation, Chemical and Environmental Hazards, Chilton, Didcot, Oxon


Getting started…

Directive 96/29/Euratom (1996) laying down basic safety standards•This source document is where we start to think about training

Directive 97/43/Euratom (1997) on health protection of individuals• Patient protection• appropriate training for the staff involved

Individual member States to enact appropriate provisions to ensure compliance


UK Health Protection Agency Guidelines

“currently little guidance available for dentists to inform them of the different radiation protection requirements” ….

European Academy of Dental and Maxillofacial Radiology “Basic Principles for use of dental CBCT” (2009).

Up until SedentexCT in 2008 there was no guidance on training


Basic PrinciplesEADMFR recognised an urgent need to set standards for CBCT use Set up a Guideline Development Panel to

develop a set of draft statements…resulted in a set of 20 “Basic Principles”


EADMFR Basic Principles on the use of CBCT

16. All those involved with CBCT must have received adequate theoretical and practical training …..

17. Continuing education and training after qualification are required, particularly when new CBCT equipment or techniques are adopted.

18. Dentists responsible for CBCT facilities who have not previously received ‘adequate theoretical and practical training’ should undergo a period of additional theoretical and practical training that has been validated.

19. For dento-alveolar CBCT images of the teeth a radiological report should be made by a specially trained DMF Radiologist or, where this is impracticable, an adequately trained general dental practitioner.


Problems

1. Few suitably qualified experts able to deliver face-to-face educational opportunities,

2. Many CBCT users may be widely scattered geographically.

provide e-learning…standard, high quality

www.conebeam.com


What training priorities do we need for CBCT?

Involved all stakeholders

1. Internet questionnaire to EADMFR members 339 members with 282 valid email addresses. 139 replies

2. Internet questionnaire to European Federation of Organizations for Medical Physics. 28 physicists replied.

3. Internet questionnaire to manufacturers. 4 replied.


Preliminary designs for “needs analysis” formulated by SedentexCT membersWeb survey content was divided into several elements:

Needs analysis – what training?Methods of delivering trainingMethods of assessment of usersBackground data on respondents

The questionnaire was piloted amongst participants in the SedentexCT consortium


What training was wanted?Rank EADMFR survey (principally dental radiologists) Rank EFOMP/ Medical Physicist survey

1 Information about Radiation doses and risks of CBCT

1 An objective technical comparison of different CBCT machines

2 A Quality Assurance Programme for users of CBCT

2 = Information about Radiation doses and risks of CBCT

3 A strategy for Radiation Protection of patients 2 = A Quality Assurance Programme for users of CBCT

4 A strategy for Radiation Protection of staff 4 Information about Quality Control Test Tools for CBCT

5 = Anatomical CBCT reference image library 5 A detailed technological description of how CBCT works

5 = Pathological CBCT reference image library 6 A strategy for Radiation Protection of patients

7 Evidence-based Referral/ Selection Criteria for CBCT

7 A strategy for Radiation Protection of staff

8 Dose Maps for CBCT 8 Dose Maps for CBCT9 Descriptions of the Dental clinical uses of CBCT 9 An image library of faults on CBCT images

10 = Information about Quality Control Test Tools for CBCT

10 A regularly updated database of links to scientific publications on CBCT

10 = An image library of faults on CBCT images 11 Evidence-based Referral/ Selection Criteria for CBCT


Manufacturers views of website contentManufacturers’ survey

Greatest need• Descriptions of the Dental clinical uses of CBCT• Descriptions of the Oral and Maxillofacial Surgery clinical uses of CBCT• Evidence-based Referral/ Selection Criteria for CBCT• An image library of faults on CBCT images• Descriptions of the “non-dental” (e.g. imaging of sinuses, middle ear)

clinical uses of CBCT• A Pathological CBCT reference image library• A regularly updated database of links to scientific publications on CBCT.

• An objective technical comparison of different CBCT machines• Information about Radiation doses and risks of CBCT• An Anatomical CBCT reference image library

• A list of available CBCT equipment on the market• A detailed technological description of how CBCT works• A strategy for Radiation Protection of staff• A strategy for Radiation Protection of patients• Information about Quality Control Test Tools for CBCT

• Pictures of available CBCT equipment on the market• Links to manufacturers’ websites• A Quality Assurance Programme for users of CBCT• Dose Maps for CBCT• A history of the development of CBCT technology

Least Need


We distilled these needs into a core curriculum

1. How does CBCT work?2. Principles of radiation dose and risk?3. Justification: net benefit4. Referral criteria 5. Radiation dose: optimization for patients and

staff6. Radiation dose: quality assurance7. Anatomy8. Interpretation of pathology


The SEDENTEXCT website


How does CBCT work - Part 1Ideas for content •Principles of imaging - how you get the volumetric data (Malmo - all)•Comparing 2D and other 3D principles of imaging (Malmo - all)Ideas about the nature of the training materials•Use a story approach (patient examination) (Malmo - all)•Look for problems for the learner to solve (Malmo - all)

Draft Learning ObjectivesKNOWLEDGE AND UNDERSTANDING•Understanding of how x-rays interact with “material” •Knowledge of the concept of the imaging “chain” from initiating the x-ray exposure to display of the image •Understanding of the difference between 2D and 3D imaging •Understanding of the basic structure and function of a CBCT machine

SKILLS AND ABILITIES

none

JUDGEMENT AND STANCE

•to attain an excellent understanding of the fundamental basis of all X-ray imaging

“Brainstorming” over the net


Module KNOWLEDGE AND UNDERSTANDING• Knowledge of the effective doses associated with CBCT and other dental X-ray techniques.• A basic understanding of how the effective dose of CBCT is influenced by equipment and patient-

related variables (introduction to optimisation).

SKILLS AND ABILITIES• to be able to communicate doses and risks of CBCT to staff and to patients effectively.

JUDGEMENT AND STANCE• to achieve an evidence-based understanding of dose and risk associated with CBCT that can be

communicated to others in easily understood language.

Radiation dose and risk


We then developed

1.Wiki2.Newsletters3.Diagnostic forum4.10 modules with Powerpoints (with voiceover)


Ensuring that stakeholder requests for training are available in the training materials

DENTISTS PHYSICISTS

Information about Radiation doses and risks of CBCT An objective technical comparison of different CBCT machines

A Quality Assurance Programme for users of CBCT Information about Radiation doses and risks of CBCT

A strategy for Radiation Protection of patients A Quality Assurance Programme for users of CBCT

A strategy for Radiation Protection of staff Information about Quality Control Test Tools for CBCT

Anatomical CBCT reference image library A detailed technological description of how CBCT works

ppt Module

ppt Module

ppt Module

ppt Moduleppt Module

.ppt Modules on Dose optimization and justification

Wiki

Wiki

Wiki

Wiki


Wiki


SedentexCT Forums:


The Future…….

SedentexCT

EADMFR

Training


Demonstration of SEDENTEXCT Website by Gareth Hughes


And finally ……

New Guidelines from SedentexCT due out next week!!


All those involved with CBCT must have received adequate theoretical and practical training for the purpose of radiological practices and relevant competence in radiation protection

ED BP

Statements derive from a combination of Basic principles and European Directive -

Others require a consensus amongst EADMFR members -

CBCT applications specialists and agents of manufactures and suppliers of CBCT equipment who provide information and training to clinical staff should obtain relevant training in radiation protection and optimization

professional education in cbct - sedentexctsedentexct.eu/system/files/prof. devlin.pdf ·...

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