Patient Management and Financial Considerations of CBCT in the Academic and

Private Practice
Frederic Barnett, DMD & Terrell F. Pannkuk, DDS, M.Sc.D.
Annual AAE Meeting Honolulu, HI, April 19, 2013


Frederic Barnett, DMD
Chairman, Department of Dental Medicine
Chairman and Program Director, IB Bender Division of Endodontics
Albert Einstein Medical Center, Philadelphia, PA
Diplomate, American Board of Endodontics

Questions to be addressed:
Does an Endodontic Residency program (the residents) benefit from having a
CBCT scanner available?
Which department controls the use of the CBCT scanner and sets the
parameters for its use? Radiology, Oral Medicine, Endodontics?
Will patients be able to pay for it? (who cares, and this is missing the point?)
Who will train the residents and faculty to read the volume?

When do we take a scan:
1. Trauma
2. Resorptionjust about every case.
3. Surgery
4. Non-localized tooth pain with equivocal findings
-uncertain pulp vitality
-obscured periapical radiograph
5. Complex anatomy
-identifying multiple canals
-determining if there are additional canals
-localizing canals that have not been found
-**intra-op scan**
6. Calcified Cases
7. Facial Pain
8. Suspected vertical root fracture
9. Endo-Perio Cases
10. Retreatments
11. Complications (perforations, separated instruments)
12. Maxillary Sinus involvement

**I ask the question when would I not want the additional information that
the scan provides?




Terrell F. Pannkuk (Private Practice), DDS, M.Sc.D.,
Diplomate of the American Board of Endodontics
Santa Barbara, CA

Questions to be addressed:
Should I get a CBCT Scanner?
How do you determine the Critical Option Determinant (COD)
How much radiation is emitted by a CBCT scan?
What are the best machines for endodontics?
How much space do you need?
Will your patients pay for it?
Do you need a radiologist to read scans for nondental pathosis?
How soon will the machine become obsolete?

Cases where a CBCT scan is valuable:

1. trauma (most cases)
2. resorptions (only if the possibility of treatment is being considered, or if
adjacent teeth are being considered for eval and identification of multiple
resorption foci)
3. surgery (most cases)
4. Nonlocalized tooth pain with equivocal findings
-uncertain pulp vitality
-obscured periapical radiograph
5. Complex anatomy (if anticipated to be exotic)
6. Calcified Cases (mid-treatment)
7. Facial Pain cases to rule out odontogenic etiology, (only if an osteolytic or
radiolucent entity is part of the differential diagnosis, but not obvious)
8. Suspected vertical root fracture
9. Endo-Perio Cases (some cases)
10. Maxillary Sinus involvement

References:

Dentomaxillofacial Radiology (2009) 38, 187195
The British Institute of Radiology, REPORT: Basic principles for use of dental cone
beam computed tomography: consensus guidelines of the European Academy of
Dental and Maxillofacial Radiology

K Horner*,1, M Islam2, L Flygare3, K Tsiklakis4 and E Whaites5
Table 3 European Academy of Dental and Maxillofacial Radiology basic principles on the use of
cone beam CT (CBCT)

1 CBCT examinations must not be carried out unless a history and clinical examination
have been performed

2 CBCT examinations must be justified for each patient to demonstrate that the benefits
outweigh the risks

3 CBCT examinations should potentially add new information to aid the patients
management

4 CBCT should not be repeated routinely on a patient without a new risk/benefit
assessment having been performed

5 When accepting referrals from other dentists for CBCT examinations, the referring
dentist must supply sufficient clinical information
(results of a history and examination) to allow the CBCT Practitioner to perform the
justification process)

6 CBCT should only be used when the question for which imaging is required cannot be
answered adequately by lower dose conventional (traditional) radiography

7 CBCT images must undergo a thorough clinical evaluation (radiological report) of
the entire image data set

8 Where it is likely that evaluation of soft tissues will be required as part of the patients
radiological assessment, the appropriate imaging should be conventional medical CT or
MR, rather than CBCT

9 CBCT equipment should offer a choice of volume sizes and examinations must use
the smallest that is compatible with the clinical situation if this provides less radiation
dose to the patient

10 Where CBCT equipment offers a choice of resolution, the resolution compatible with
adequate diagnosis and the lowest achievable dose should be used

11 A quality assurance program must be established and implemented for each CBCT
facility, including equipment, techniques and quality control procedures

12 Aids to accurate positioning (light beam markers) must always be used

13 All new installations of CBCT equipment should undergo a critical examination and
detailed acceptance tests before use to ensure that radiation protection for staff,
members of the public and patient are optimal

14 CBCT equipment should undergo regular routine tests to ensure that radiation
protection, for both practice/facility users and patients, has not significantly deteriorated

15 For staff protection from CBCT equipment, the guidelines detailed in Section 6 of the
European Commission document Radiation Protection 136. European guidelines on
radiation protection in dental radiology should be followed

16 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

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 by an academic institution (university or
equivalent). Where national specialist qualifications in DMFR exist, the design and
delivery of CBCT training programmes should involve a DMF Radiologist

19 For dentoalveolar CBCT images of the teeth, their supporting structures, the
mandible and the maxilla up to the floor of the nose (e.g. 8 cm, 6 -8 cm or smaller fields
of view), clinical evaluation (radiological report) should be made by a specially trained
DMF Radiologist or, where this is impracticable, an adequately trained general dental
practitioner

20 For non-dentoalveolar small fields of view (e.g. temporal bone) and all craniofacial
CBCT images (fields of view extending beyond the teeth, their supporting structures, the
mandible, including the TMJ, and the maxilla up to the floor of the nose), clinical
evaluation (radiological report) should be made by a specially trained DMF
Radiologist or by a Clinical Radiologist (Medical Radiologist)



AAE Colleagues for Excellence, Summer 2011 Cone Beam Computed
Tomography in Endodontics
For most endodontic applications, limited or focused FOV CBCT is preferred over large
volume CBCT for the following reasons:
1. Increased resolution to improve the diagnostic accuracy of endodontic-specific tasks
such as the visualization of small features including calcified/accessory canals, missed
canals, etc.
2. Highest possible resolution.
3. Decreased radiation exposure to the patient.
4. Time savings due to smaller volume to be interpreted.
5. Smaller area of responsibility.
6. Focus on anatomical area of interest.






Ionizing Radiation Dosages (approximate)
Activity Effective Dose in Sv Dose as Days of Equivalent Background Radiation
Ionizing Radiation Dosages

Dose as Days of Equivalent Activity Effective Dose (in microSieverts)
Background Radiation

1 day background radiation (sea level) 7-8
1

1 digital PA radiograph 6
1

4 dental bitewing radiographs (F speed film) 38
5

FMX- 18 PA radiographs (F speed film) 171
21

Kodak CBCT focused field, anterior 4.7
0.71

Kodak CBCT focused field, max posterior 9.8
1.4

Kodak CBCT focused field, mand posterior 38.3
5.47

3D Accuitomo (mfr J. Morita) 20
3

NewTom 3G (mfr ImageWorks) 68
8

Chest Xray 170
25

Mammogram 700
106

Medical CT (head) 2,000
243

Medical CT (spiral abdomen) 10,000
1,515

Federal Occupation Safety Limit per year 50,000
7,575


ALARA Principle:As Low as Reasonable Achievable

In general, the use of CBCT in endodontics should be limited to the assessment and
treatment of complex endodontic conditions such as:
Identification of root canal system anomalies and determination of root curvature.
Diagnosis of dental periapical pathosis in patients who present with contradictory or
nonspecific clinical signs and symptoms, who have poorly localized symptoms
associated with an untreated or previously endodontically treated tooth with no evidence
of pathosis identified by conventional imaging, and in cases where anatomic
superimposition of roots or areas of the maxillofacial skeleton is required to perform
task-specific procedures.
Diagnosis of pathosis of nonendodontic origin in order to determine the extent of the
lesion and its effect on surrounding structures.
Intra- or postoperative assessment of endodontic treatment complications, such as
overextended root canal obturation material, separated endodontic instruments,
calcified canal identification and localization of perforations.
Diagnosis and management of dentoalveolar trauma, especially root fractures, luxation
and/or displacement of teeth, and alveolar fractures.
Localization and differentiation of external from internal root resorption or invasive
cervical resorption from other conditions, and the determination of appropriate treatment
and prognosis.
Presurgical case planning to determine the exact location of root apex/apices and to
evaluate the proximity of adjacent anatomical structures.

Detection of Vertical Root Fractures in Endodontically Treated Teeth by a Cone
Beam Computed Tomography Scan
Bassam Hassan, BDS, MSc,* Maria Elissavet Metska, DDS, MSc, Ahmet Rifat Ozok, DDS,
PhD, Paul van der Stelt, DDS, PhD,* and Paul Rudolf Wesselink, DDS, PhD
J Endod 2009;35:719722)
Abstract
Our aim was to compare the accuracy of cone beam
computed tomography (CBCT) scans and periapical
radiographs (PRs) in detecting vertical root fractures
(VRFs) and to assess the influence of root canal filling
(RCF) on fracture visibility. Eighty teeth were endodontically
prepared and divided into four groups. The teeth
in groups A and B were artificially fractured, and teeth in
groups C and D were not. Groups A and C were root
filled. Four observers evaluated the CBCT scans and
PR images. Sensitivity and specificity for VRF detection
of CBCT were 79.4% and 92.5% and for PR were
37.1% and 95%, respectively. The specificity of CBCT
was reduced (p = 0.032) by the presence of RCF, but
its overall accuracy was not influenced (p = 0.654).
Both the sensitivity (p = 0.006) and overall accuracy
(p = 0.008) of PRs were reduced by the presence of
RCF. The results showed an overall higher accuracy for
CBCT (0.86) scans than PRs (0.66) for detecting VRF.
Clinical indications for digital imaging in dento-alveolar trauma. Part 2: root
resorption.
Cohenca N, Simon JH, Mathur A, Malfaz JM. Dent Traumatol. 2007 Apr;23(2):105-13.

Common complications of dento-alveolar trauma are pulp necrosis, pulp canal
obliteration, periapical pathosis and root resorption. Different types of root
resorption have been identified with traumatic injuries. Repair-related
(surface), infection-related (inflammatory), ankylosis-related (osseous
replacement) or extraradicular invasive cervical resorption are among the most
common. Recent developments in imaging systems have enabled clinicians to
visualize structural changes effectively. The diagnosis and three-dimensional
imaging assessment of the resorption is important in order to determine the
treatment complexity and expected outcome based on the location and extension of
the root defect. This article discusses and illustrates the clinical application
of cone beam computed tomography for diagnosis and treatment plan of root
resorption. Four clinical cases are presented to illustrate the potential use of
the NewTom 3G for root resorption.


Clinical indications for digital imaging in dento-alveolar trauma. Part 1:
traumatic injuries.
Cohenca N, Simon JH, Roges R, Morag Y, Malfaz JM. Dent Traumatol. 2007 Apr;23(2):95-104.

Traumatized teeth present a clinical challenge with regard to their diagnosis,
treatment plan, and prognosis. Recent developments in imaging systems have
enabled clinicians to visualize structural changes effectively. Computed
tomography, magnetic resonance imaging and cone beam computed tomography are
among the most commonly used systems for dental and maxillofacial surgery. The
purpose of this review is to describe the advantages and disadvantages of each
technique and the clinical application for dento-alveolar trauma. Three clinical
cases are described to illustrate the potential use of the NewTom 3G for
diagnosis and treatment plan of dento-alveolar traumatic injuries.


Diagnostic yield of conventional radiographic and cone-beam computed tomographic
images in patients with atypical odontalgia.
Pigg M, List T, Petersson K, Lindh C, Petersson A. Int Endod J. 2011 Dec;44(12):1092-101.

AIM: To investigate whether the additional diagnostic yield of a cone-beam
computed tomography (CBCT) examination over conventional radiographs in patients
primarily suspected of having atypical odontalgia (AO) improves differentiation
between AO and symptomatic apical periodontitis (SAP) in patients with severe
chronic intraoral pain.
METHODOLOGY: In this clinical study, 25 patients (mean age 54 11 years, range
34-72) participated; 20 were diagnosed with AO and 5 with SAP. All patients were
recruited from the clinics of the Faculty of Odontology, Malm University. AO
inclusion criteria were chronic pain (>6 months) in a region where a tooth had
been endodontically or surgically treated, with no pathological cause detectable
in clinical or radiologic examinations. SAP inclusion criteria were recurrent
pain from a tooth diagnosed with apical periodontitis in clinical and
radiographic examinations. Assessments comprised a self-report questionnaire on
pain characteristics, a comprehensive clinical examination and a radiographic
examination including panoramic and intraoral radiographs and CBCT images. The
main outcome measure was periapical bone destruction.
RESULTS: Sixty per cent of patients with AO had no periapical bone destructions
detectable with any radiographic method. Overall, CBCT rendered 17% more
periapical bone destructions than conventional radiography. Average pain
intensity in patients with AO was 5.6 ( 1.8) on a 0-10 numerical rating scale,
and average pain duration was 4.3 ( 5.2) years.
CONCLUSION: Cone-beam computed tomography improves identification of patients
without periapical bone destruction, which may facilitate differentiation between
AO and SAP.


Diagnostic accuracy of small volume cone beam computed tomography and intraoral
periapical radiography for the detection of simulated external inflammatory root
resorption.
Durack C, Patel S, Davies J, Wilson R, Mannocci F. Int Endod J. 2011 Feb;44(2):136-47.

Aim: To compare in an ex vivo model the ability of digital intraoral radiography
and cone beam computed tomography (CBCT) to detect simulated external
inflammatory root resorption lesions, and to investigate the effect of altering
the degree of rotation of the CBCT scanners X-ray source and imaging detector on
the ability to detect the same lesions.METHODOLOGY: Small and large simulated
external inflammatory resorption (EIR) lesions were created on the roots of 10
mandibular incisor teeth from three human mandibles. Small volume CBCT scans with
180 and 360 of X-ray source rotation and periapical radiographs, using a
digital photostimulable phosphor plate system, were taken prior to and after the
creation of the EIR lesions. The teeth were relocated in their original sockets
during imaging. Receiver operator characteristic (ROC) analysis and kappa tests
of the reproducibility of the imaging techniques were carried out and
sensitivity, specificity, positive and negative predictive values (PPV and NPV)
were also determined for each technique.
RESULTS: The overall area under the ROC curve (Az value) for intraoral
radiography was 0.665, compared to Az values of 0.984 and 0.990 for 180 and 360
CBCT, respectively (P<0.001). The sensitivity and specificity of 180 and 360
CBCT were significantly better than intraoral radiography (P<0.001). CBCT,
regardless of the degree of rotation, had superior NPVs (P<0.01) and PPVs
(P<0.001) to periapical radiography. The intra- and inter-examiner agreement was
significantly better for CBCT than it was for intraoral radiography (P<0.001).
The ability of small volume CBCT to detect simulated EIR was the same regardless
of whether 180 or 360 scans were taken. Examiners were significantly better
able to identify the exact location of the artificial resorption lesions with
CBCT than they were with periapical radiographs (P<0.001).
CONCLUSION: CBCT is a reliable and valid method of detecting simulated EIR and
performs significantly better than intraoral periapical radiography. Small volume
CBCT operating with 360 of rotation of the X-ray source and detector is no
better at detecting small, artificially created EIR cavities than the same device
operating with 180 of rotation.



A comparative study between cone-beam computed tomography and periapical
radiographs in the diagnosis of simulated endodontic complications.
D'Addazio PS, Campos CN, zcan M, Teixeira HG, Passoni RM, Carvalho AC. Int Endod J.
2011 Mar;44(3):218-24.

AIM: To compare cone-beam computed tomography (CBCT) with periapical radiography
for the identification of simulated endodontic complications.
METHODOLOGY: Sixteen human teeth, in three mandibles, were submitted to the
following simulated endodontic complications: G1) fractured endodontic file; G2)
root perforation; G3) cast post with deviation; G4) external root resorption.
Periapical radiographs were taken of each tooth at three different angles, and
CBCT scan was taken. One calibrated examiner who was specialized in dental
radiology interpreted the images. The results were analysed using the following
scoring system: 0 - unidentified alteration; 1 - alteration identified with
inaccurate diagnosis; and 2 - alteration identified with accurate diagnosis. Data
were analysed using McNemar and Wilcoxon tests (alfa=0.05).
RESULTS: In the overall assessment, CBCT was superior when compared with
periapical radiographs (P<0.05). When individual results on each complication
were evaluated, CBCT was superior only in the identification of external root
resorption (100% Score 2) (P<0.05).
CONCLUSION: Cone-beam computed tomography could be an alternative to periapical
radiographs especially in the detection and assessment of external root
resorption.


Method to evaluate inflammatory root resorption by using cone beam computed
tomography.
Estrela C, Bueno MR, De Alencar AH, Mattar R, Valladares Neto J, Azevedo BC, De
Arajo Estrela CR. J Endod. 2009 Nov;35(11):1491-7.

INTRODUCTION: The aim of this study was to evaluate a method to measure
inflammatory root resorption (IRR) by using cone beam computed tomography (CBCT)
scans.
METHODS: IRR sites were classified according to root third and root surface, and
IRR extension was measured on the axial, transverse, and tangent views of
3-dimensional CBCT scans by using the Planimp software. A 5-point (0-4) scoring
system was used to measure the largest extension of root resorption. A total of
48 periapical radiographs and CBCT scans originally taken from 40 patients were
evaluated. The kappa coefficient was used to assess interobserver agreement and
the chi(2) test to determine significant differences between the imaging methods.
The level of significance was set at alpha = 1%.
RESULTS: IRR was detected in 68.8% (83 root surfaces) of the radiographs and 100%
(154 root surfaces) of the CBCT scans (P < .001). The extension of IRR was >1-4
mm in 95.8% of the CBCT images and in 52.1% of the images obtained by using the
conventional method (P < .001).
CONCLUSIONS: CBCT seems to be useful in the evaluation of IRR, and its diagnostic
performance was better than that of periapical radiography.

The detection and management of root resorption lesions using intraoral
radiography and cone beam computed tomography - an in vivo investigation.
Patel S, Dawood A, Wilson R, Horner K, Mannocci F. Int Endod J. 2009 Sep;42(9):831-8.

AIM: To compare the accuracy of intraoral periapical radiography with cone beam
computed tomography (CBCT) for the detection and management of resorption
lesions.
METHODOLOGY: Digital intraoral radiographs and CBCT scans were taken of patients
with internal resorption (n = 5), external cervical resorption (n = 5) and no
resorption (controls) (n = 5). A 'reference standard' diagnosis and treatment
plan was devised for each tooth. Sensitivity, specificity, positive predictive
values, negative predictive values and receiver operator characteristic (ROC)
curves, as well as the reproducibility of each technique were determined for
diagnostic accuracy and treatment option chosen.
RESULTS: The intraoral radiography ROC Az values were 0.780 and 0.830 for
diagnostic accuracy of internal and external cervical resorption respectively.
The CBCT ROC Az values were 1.000 for both internal and external cervical
resorption. There was a significantly higher prevalence (P = 0.028) for the
correct treatment option being chosen with CBCT (%) compared with intraoral
radiographs (%).
CONCLUSION: CBCT was effective and reliable in detecting the presence of
resorption lesions. Although digital intraoral radiography resulted in an
acceptable level of accuracy, the superior accuracy of CBCT may result in a
review of the radiographic techniques used for assessing the type of resorption
lesion present. CBCT's superior diagnostic accuracy also resulted in an increased
likelihood of correct management of resorption lesions.


Intraoperative endodontic applications of cone-beam computed tomography.
Ball RL, Barbizam JV, Cohenca N. J Endod. 2013 Apr;39(4):548-57.

Abstract
INTRODUCTION: The use of cone-beam computed tomography (CBCT) in endodontics for
diagnosis, treatment planning, and follow-up has been extensively reported in the literature.
Compared with the traditional spiral computed tomography, high-resolution limited CBCT
results in a fraction of the effective absorbed dose of radiation. However, it should be prescribed
only after weighing the cost of radiation exposure with the benefit of the diagnostic information
that can be obtained from the scan.
METHODS: The purpose of this article is to discuss the application and advantages of
intraoperative CBCT in endodontics, while reducing radiation exposure during complex
endodontic procedures.
RESULTS: In cases of increased difficulty or intraoperative complications such as complex
anatomy, dystrophic calcifications, root resorptions, perforations, and root fractures, it is prudent
to consider the use of CBCT with its inherent diagnostic value and limited radiation exposure.
CONCLUSIONS: The benefits of the added diagnostic information provided by intraoperative
CBCT images in select cases justify the risk associated with the limited level of radiation
exposure.