ADVANCED DIAGNOSTIC AIDS

PRESENTED BY G. SRINIVAS 2nd YEAR PG DEPT OF PERIODONTICS DATE: 8/2/12

Contents
Introduction Definition History Principles of diagnosis Clinical evaluation of periodontal disease Diagnostic methods Advances in Clinical diagnosis Advances in Radiographic Assessment Advances in Microbiologic Analysis Advances in Characterizing the Host Response

Introduction
Periodontitis Proper diagnosis is essential to intelligent treatment. Periodontal diagnosis should first determine whether disease is present; then identify its type, extent, distribution, and severity; and finally provide an understanding of the underlying pathologic processes and its cause.

 Periodontal diagnosis is determined after careful analysis of the case history and evaluation of the clinical signs and symptoms, as well as the results of various tests (e.g., probing, mobility assessment, radiographs, blood tests, and biopsies)

Microbiologic, immunologic, systemic, genetic and behavioral factors should include in addition to the traditional clinical and radiographic parameters, when assessing patient status.

Definition
Diagnosis of disease is the process by which the clinician attempts to assign a label to a set of signs and symptoms gleaned from an interview, a clinical examination and assays gathered from the patient.

History
Early approaches to diagnosis: The earliest diagnostic procedures were based on physical signs and symptoms. In ancient China, inflammatory lesions of the gingiva were recognized by changes in tooth mobility and fetid breath ---Bremner MDK. Hippocratic clinical diagnosis of periodontal disease described changes in the gingival color associated with bad breath ----Gold SI.

 So the earliest instruments for describing disease have been the senses of touch, sight, smell and, to a lesser extent, taste and hearing. The first thorough codification of dental disease was published by Pierre Fauchard. His descriptions of gingival and periodontal diseases included changes in color and form of the gingiva, recession, tooth mobility, pain and fetor ex oris.

 John Hunter recorded swelling, tenderness and bleeding upon slight provocation in cases of scurvy of the gums.

Joseph Fox recognized variations in gingival recession as well as the variations in morphology of calculus.

Clinical evaluation of periodontal disease

Early champions of the local etiology theory for periodontal diseases included Riggs and John Younger . In Colyers description of periodontal disease, he noted that the tags of gum between the teeth (papillae) gradually disappear and the normal festoons become obliterated.

 The periodontal probe was the first attempt to quantify the data documenting the severity of periodontal disease.

G.V. Black was the first to describe the systematic use of a probe to explore periodontal pockets.

Merritt is the designer of a popular clinical probe.

 Although G.V. Black has long been recognized as the father of conservative dentistry, his text A work on special dental pathology provided the first important histological description of the periodontium.

Non calibrated periodontal probes of the type advocated by G.V. Black

 Listgarten noted that probing depth seldom corresponds to pocket depth. Examination of the occlusion and recording tooth mobility has been a part of the diagnosis of periodontal disease. Miller proposed a graduated mobility scale for recording lateral movement when a tooth was displaced between 2 instrument handles.

 Muhlemann developed a device for recording horizontal tooth displacement with greater precision.

Picton designed another instrument for the same purpose but, as with Muhlemanns periodontometer, it was used mainly for clinical research.

In 1980 Stoller, Laudenbach proposed a standard clinical scale with 3 gradations much like that originally described by Miller and later refined by Muhlemann and Prichard.

 This dental light popularized in the 1920s was only possible after rural electrification was available. Prior light sources included daylight, kerosene, gas and acetylene. Poor illumination was a severe limitation to accurate diagnostic procedures.

Principles of Diagnostic Testing

1. Sensitivity = no. of subjects who test positive no. of subjects with disease 2. Specificity= no. of subjects who test negative no. of subjects without disease 3. Predictive value: +ve & -ve

4. Likelihood ratios: Likelihood ratios can be used to evaluate the performance of a diagnostic test that is dichotomous or has interval properties. Likelihood ratios can be used to calculate the probability of disease after a positive or negative test result. 5. Sample size: affects the precision of our estimates and the amount of variability present . Sample size also affects estimates of sensitivity, specificity, and likelihood ratios.

Diagnostic methods
3 categories based on their features and clinical aspects. 1. a clinical examination, which is the mainstream, or gold standard of current practice, primarily measures clinical parameters such as BOP, PPD, CAL.

2. genetic analyses and laboratory-type tests measure aspects of oral biochemistry, microbiology, or radiography.

3. newly emerging noninvasive techniques, such as - Molecular fingerprinting with infrared (IR) -Spectroscopy and -Morphologic imaging using optical coherence tomography (OCT) or ultrasound.

Advanced diagnostic aids

Considerable advances have been made 1. Advances in Clinical diagnosis 2. Advances in Radiographic Assessment 3. Advances in Microbiologic Analysis 4. Advances in Characterizing the Host Response

Advances in Clinical diagnosis

Gingival bleeding: Clinical evaluation of the degree of gingival inflammation includes assessment of the redness and swelling of the gingiva along with assessment of gingival bleeding. -Indicator of inflammatory lesion -Relation to disease activity is unclear. -Normal probing force is 0.25N ---Lang. -Presence is not a indicator but absence indicates health.

 Several studies have shown that gingival bleeding is a sensitive clinical indicator of early gingival inflammation --- Mombelli A, Graf H.

sites that bled on probing at several visits had a higher probability of losing attachment than those that bled at one visit or did not bleed -----Lang et al.

Gingival temperature
Early studies by King et al 1990-linked subgingival temperature with periodontal pocketing. Maxillary periodontal sites are hotter than mandibular Posterior sites are hotter than anterior sites ----Haffajee et al 1992.

 There is a positive correlation between elevated subgingival temperature and -Severity of disease -Degree of gingival inflammation -Presence of putative pathogens. Subgingival temperature, like other signs of inflammation has good specificity but poor sensitivity when considered alone as a marker for progressive periodontitis.

Periotemp probe: (Abiodent, Inc., Danvers, Mass.) detects pocket temperature differences of 0.1 C from a referenced subgingival temperature.

Detecting Mobility
Periotest :
Schulte in collaboration with Siemens company developed Perio test. Measures the mobility of Implants and teeth Percussed at 4times/sec and the degree of attenuation is scaled from -8 to +50 and recorded digitally.

Periodontal probing
Widely used diagnostic tool for measurement of CAL . Increased pocket depth and loss of clinical attachment level is pathognomonic sign for periodontitis.

 Clinical pocket depth does not coincide with the histologic pocket depth because probe penetrates the coronal level of the junctional epithelium.

If the tissues are also inflammed then the tissue offer's less resistance to probe penetration false reading is obtained ----- Listgarten MA.

The difference in measurements depends upon the

Probing technique Probing force Size of the probe Angle of insertion of the probe Precision of the probe calibration ------Chen C, Slots J

 Probing forces with conventional instruments vary widely from 3 to 140g among clinicians and sites in the dentition (Hassel et al 1971&1973). Forces up to 30 gm the tip of the probe seems to be in the junctional epithelium ---- Armitage GC, Svanberg GK. Forces up to 50 gm - necessary to diagnose periodontal osseous defects ---- Kalkwarf KL. The mean probing force among periodontists has been reported to range from about 17.0g to 55.0g (Freed et al 1983)

Various generations of probe development:

Pihlstrom 1992 described 3 generations Generation I: conventional probes. Generation II: Pressure sensitive. Generation III: Computerized. Generation IV & V probes are currently under development.

 Generation IV probes aim at recording sequential probing positions along the gingival sulcus.

Generation V: would have an ultrasound device attached to the fourth generation probe for identifying attachment level without penetrating it.

first generation probes

Pressure sensitive second generation probe

NIDCR Criteria defining conventional probes

Precision Range Probing force Applicability Reach Angulation Security : 1 millimeter : 12 millimeter : Not standardized : Non invasive & easy to use : Easy to access any location : Subjective : Simple stainless steel instrument-easily sterilizable : On voice dictation : In writing

Read out Recorded

Criteria defined by NIDCR for automated probes

Precision Range Probing force Applicability Reach Angulation Security : : : : : : : 0.1 millimeter 10 millimeter Constant & standardized Non invasive ,light weight & easy to use Easy to access any location Guidance system to ensure proper angulation Complete sterilization of all portions entering the mouth. No bio hazard from material/ electric shock. Digital electronic reading & digital output

Currently used automated probes

FLORIDA PROBE ( GIBBS et al): Features Constant probing force Precise electronic measurement Computer storage of data Precise early detection of disease Clear graphic charting

Components
Probe hand piece Digital read out 3- Pedal foot switch Computer interface and Computer

Features of hand piece

Probe tips are manufactured by micro polishing technique Constant force measurements in 0.2 mm Probe tips are 0.4 mm in diameter made of implant grade titanium Can be steam sterilized in a standard autoclave

Three Pedal foot switch

Solo operator may enter all data Eliminates error in visual reading Less contamination

Computer interface
Pocket depth & bleeding sites called out automatically using sound effects from computer Color coded digital read outs Educates and motivates patient

Models of florida probe

Two models Stent model Has 1 millimeter metal collar that rests on a prepared ledge on a prefabricated vaccuoform stent. Disk model Has 1 millimeter disk which rests on the occlusal surface/ incisal edge of tooth.

 The disk is placed on the occlusal/incisal surface while measuring the probing pocket depth.
One common problem reported in different studies where the Florida Probe System has been compared with conventional probing is the underestimation of deep probing depths by the automated probe ----- Perry DA, Taggart EJ, Leung A.

FP Handpiece tip as it enters the sulcus.

FP Handpiece tip with constant force in use (tip at bottom of sulcus) and sleeve properly positioned at the top of the gingival margin allowing the computer to measure the difference (3.0 mm).

 Studies have clearly shown that with the use of trained operators and performing the "double pass" method the measurements taken with the Florida Probe System are significantly less variable (lower standard deviation) than those obtained with a conventional probe ----- Rams TE, Slots J.

Interprobe/Periprobe System
Goodson Jm & Kondran N in 1988 developed interprobe using fiber optic technology Electronic probing systems, such as the Interprobe System or the Periprobe System, are also commercially available. They provide -constant probing force, -computer storage of data, and -precise electronic management of the resulting inflammation.

Jeffcoat probe (Foster Miller probes)

Automatically extends & retracts under controlled force Rapid change in acceleration when C-E Junction is crossed Working end of probe has Michigan O probe markings Internal moving tip Teflon coated stainless steel wire Circular in cross section & 0.15 millimeter in diameter Probe motion provided by custom low friction pneumatic cylinder

Toronto probes
Karim et al (1990) introduced this probe. This probe has been incorporated with a tilt sensor device in its handle so that changes in angulation of the probe could be measured and corrected. Sulcus probed with 0.5-millimeter nickel - titanium wire under air pressure Mercury tilt sensor limits angulation within 30o

Birek probe

Works under constant air pressure Uses occlusal surface as reference

UltraSonographic Perio Probe

A painless way to monitor periodontal disease
No reliable clinical indicators of disease activity need Gold Standard Mechanical probing inaccurate, subjective, slow, painful Subtraction radiography only shows bone loss Diagnostic ultrasound is widely used in other areas of medicine

Ultrasonography in Medicine

Baby Face in the Womb

Echocardiography Examples

Transrectal ultrasound of Prostate

Probe tip is placed at gum line with thin ultrasound beam projecting into tissues.
Ultrasound Transducer

Probe Handpiece

Ultrasound waves in coupling water are focused inside of tip to a very thin beam Crest of periodontal ligament reflects ultrasound beam. Echoes are recorded by ultrasound transducer and then analyzed by computer expert system.

Better balance and feel with contra-angling for easier use

Probe CAD Drawing

Industry standard quick disconnect for both cable and coupling water line

Water & Electronics Line

Current Version of Periodontal Probe: Design to Practice to Clinical Tests

Probe Tips & Transducers

Probe tip is placed at gum line with thin ultrasound beam projecting into the periodontal tissues.

-Easy to Use Computer Interface -Will be integrated into practice-management software

Foot pedal starts flow of coupling water, records & archives data, increments

Expected Product Line

Base Model is Walking Probe Smartly packaged version of current system Mid-Range Model is Scanning Probe Magnetic tracking allows continuous mapping High-End Model is Imaging Probe B-mode imager for perio offices & researchers Many Follow-on Probes Crack Finder, Root Assessor, Implant Checker Interchangeable handpieces for perio probes

The dental endoscope

For use subgingivally in the diagnosis and treatment of periodontal disease. Produced by Dental View, Inc.- called as Perioscopy system. Consists of 0.99mm diameter reusable fibroptic endoscope over which is fitted a disposable, sterile sheath.

 The fibroptic endoscope fits on to the periodontal probes and ultrasonic instruments that have been designed to accept it. The sheath delivers water irrigation that flushes the pocket while the endoscope is in use and keeps the field clear. The fibroptic endoscope attaches to a Medical grade Charged Coupled Device [CCD], Video camera and Light source that produces a image on a flat panel video monitor for viewing during subgingival exploration and instrumentation.

 Perioscope

Fibroptic sheath

Uses
Allows clear visualization of deep subgingival pockets and furcations.

Enables operator to detect the presence and location of subgingival deposits and guides the operator in their removal.

 Using this device it is possible to achieve levels of root debridement and cleanliness that are much more difficult to produce without it. Can also be used to evaluate subgingivally For -caries, -Defective restorations, -Root fractures and -Resorption.

II. Advances in Radiographic Assessment

Dental radiographs are the traditional method used to assess the destruction of alveolar bone associated with periodontitis. Traditional method used to assess the destruction of alveolar bone associated with periodontal disease. Provide information regarding interproximal bone levels rather than buccal /lingual plates.

 Provide information on the periodontium that cannot be obtained by any other non invasive methods: E.g,., Root length, Root proximity Presence of periapical lesions and Estimates remaining alveolar bone.

 It is well known that substantial volumes of alveolar bone must be destroyed before the loss is detectable in radiographs ----Goodson JM, Haffajee AD, Socransky SS Specifically, more than 30% of the bone mass at the alveolar crest must be lost for a change in bone height to be recognized on radiographs ----Ortman LF, McHenry K, Hausmann E. Therefore conventional radiographs are very specific, but lack sensitivity.

 The distance from the CEJ to the alveolar crest as measured from bite-wing radiographs.

Studies has used >2mm as criterion for bone loss (Aas et al 1989).

Variability affecting conventional radiographs are

Variations in projection geometry. This can be reduced by the use of well-standardized long cone parallel technique. Variations in contrast and density of the film. This may occur due to the difference in film processing, voltage and exposure time. Masking of osseous changes by other anatomic structures.

What should be done to standardize the radiographic assessment?

Radiographs should be obtained in a constant and reproducible plane

Using film holders with template containing impression material, which is placed in a constant position on a group of teeth and an extension arm can be precisely attached to both the film holder and the x ray tube.

Digital radiography
Digital radiography enables the use of computerized images which can be stored, manipulated and corrected for under/over exposures By digital storage and processing, diagnostic information can be enhanced -----Hausmann E. Dose reduction of radiation is obtained with digital than conventional radiography i.e., between 1/3 to of dose reduction is obtained.

Direct method
Uses a charged couple device [CCD] sensor linked with a fiber optic or other wire to the computer system.

This method obtains real time imaging offering both the clinician and the patient an improved visualization of the periodontium by image manipulation and comparison with previously stored images.

Main disadvantage
Limited sensor area, enough to depict one or two teeth The sensor rigidity attached to wire, which besides sterility issues makes ideal image projection very difficult when using film holders.

Indirect method: Digora system

Uses a phosphor luminescence plate which is a flexible film like radiation energy sensor placed intraorally and exposed to conventional x ray tubes.

A laser scanner reads the exposed plates offline and reveals digital image data, which can be enhanced, stored and compared with previous images.

 Digital Radiographic System-Digora. Digitized radiographs can be used for patient education and for demonstrating the effects of therapy.

Advantages
The real advantage is due to the plate size and flexibility, which is identical to conventional x ray films [paralleling technique can be used easily]

Due to the clear advantage of real /almost real images, that can be improved/ modified, this will soon replace conventional radiographs.

 It is an important educational component of online images which can be presented to the patient.

Digital radiography is in a state of rapid development. Sensors as well as computer software and hardware being used are constantly modified and improved.

Subtraction radiography
History: First introduced by Zeiidses del Plantes[in medicine]. Grondahl HG, Grondahl K, in 1983 introduced in periodontal diagnosis. Jeffcoat in 1992 used this for determination of periodontal disease progression.

 Studies using this technique have shown (1) a high degree of correlation between changes in alveolar bone determined by subtraction radiography and attachment level changes in periodontal patients after therapy ----Hausmann E (2)increased detectability of small osseous lesions

 Grondahl et al," using subtraction analysis, showed nearly perfect accuracy at a lesion depth corresponding to 0.49 mm of compact bone, whereas a lesion must be at least three times larger to be detectable with a conventional radiology technique. Subtraction radiography has also shown a degree of sensitivity similar to that for I 125 absorptiometry -----Hausmann E, McHenry K, Christersson L, It can detect a change in bone mass of as little as 5% ---Ortman LF, McHenry K, Hausmann E

Technique
The technique relies on the conversion of serial radiographs into digital images.

The serially obtained digital images can then be superimposed and the resultant composite viewed on a video screen.

Inference
Changes in the density and/ or volume of bone can be detected as Lighter areas bone gain Darker areas - bone loss. Quantitative changes in comparison with the baseline can be detected using an algorithm for gray scale levels.

 Hausmann et al detected significant differences in crestal bone height of 0.87 mm.

Jeffcoat et al showed a strong relationship between probing attachment loss and bone loss detected with digital subtraction radiography.

 The main disadvantage of digital subtraction radiography techniques is the need to be close to identical projection alignment during the exposure of the sequential radiographs, which makes this method very impractical in a clinical setting.

Recently, new image subtraction methods (diagnostic subtraction radiography [DSR]) have been introduced.

Diagnostic substraction radiography [DSR]

Combining the use of a positioning device during film exposure with specialized software designed for digital image substraction using conventional personal computers in dental offices. This image analysis software, applies an algorithm that corrects for the effects of angular alignment discrepancies and provides some degree of flexibility in the imaging procedure.

When compared with conventional and susbstraction radiography Statistically significant gains in diagnostic accuracy over conventional radiographs. No differences against the classical substraction radiography [Nummikoski et al 2000] This method has great diagnostic potential, especially in clinical practice, because of the development of personal computers with capability for digitizing and image processing.

 Digital Subtraction Analysis (DSR) can be used to evaluate the effects of therapy on bone density and morphology.

The effects of surgical therapy on an angular defect are seen, with the new bone formation represented by the dark area.

Computer assisted densitometric image analysis

It is a video based system, in which a video camera measures the light transmitted through a radiograph and the signals from the camera are converted into gray scale images. ----- Bragger U, Pasquali L, Rylander H The camera is interfaced with a image processor and a computer that allow the storage and mathematical manipulation of the images.

 It offers an objective method for following alveolar bone density changes quantitatively over time. When compared with I 125-absorptiometry digital substraction analysis, it shows higher sensitivity and high degree of reproducibility and accuracy. Using replicate measurements of CAL and CADIA, it has been shown that the prevalence of progressing lesions in periodontitis is much higher than that previously thought [Daes et al 1991].

Computed tomography
It is a radiographic technique that can display an image on a gray scale using a television monitor. First introduced by G.V Hounsfield early 1970s. CT scanner has 4 components: - The computerized patient bed - A gantry containing an x ray tube and a large array of x ray sensitive detectors. -Microprocessors for data analysis. - A television monitor and filing device for hard copies.

 The latest scanners use a ring of detectors that surround the patient and remain stationary as the x ray tube rotates reducing scan tissues. Generally, each CT image or slice is 1 1.5mm thickness. The thinner the slice, more noise or distortion will be produced.

 The CT scanner generally makes axial slices of a given area approx 1.0 mm apart. They are called as axial slices because they are made perpendicular to the long axis of the body. These slices are made as close to parallel to the edentulous site or occlusal plane as possible

The microprocessor can then create a series of Panoramic views Coronal views Cross sectional views[oblique]

Generations of CT
CT technology rapidly underwent five developmental generations.

 3. First-generation CT scanner

4. Second-generation CT scanner

 3. Third-generation CT scanner 5. fifth-generation CT scanner

4. Fourth-generation CT scanner

Uses
Irregular thin or spiny osseous contours may be discernible from CT scans Soft tissue contour and dimension Continuity and density of cortical plates Vertical height of the residual alveolar ridges, density of the medullary spaces and basilar bone. Used to determine how much space available above the mandibular canal to receive a dental implant. To determine whether there's a space occupying lesion in the maxillofacial region.

Disadvantage
Highly expensive High radiation burden Should be used when answers cant be obtained by clinical examination or conventional transmission radiography

Magnetic Resonance Imaging

Widely used recently. MR images are obtained by measuring changes in low frequency audio signals in the magnetic field. The resulting data is used to create images of structures examined. It provides better soft tissue images than CT Pt not exposed to radiation.

Uses
Mainly used at present in the study of TMJ and the soft tissue lesion of the gingiva and the other oral structures.

Finds application in placement of implants.

Ultrasonography
Useful, painless, non invasive procedure. Used in periodontal diagnosis for : Examination of hard tissues Periodontal ligament space Determine bone morphology Measurement of furcation involvement.

Nuclear medicine techniques [bone scanning]

Detect changes in bone metabolism that may precede or accompany architectural changes. Mid -1970s Goldhaber and coworkers first began to apply nuclear medicine techniques to the study of periodontal bone resorption.

 This involves use of radio labeled boneseeking pharmaceutical such as Technetium99m, a short lived element with 6 hour physical half life. Technetium is characterized by its ability to complex with carrier agents and creates tissue specific radio pharmaceuticals.

 For bone studies, the Technetium label is complexed with Tin and a Disphophonate moiety, giving the radio pharmaceutical its bone seeking quality. To examine bone, radiophor is injected intravenously, and a lag time of 1-2 hours is required for clearance from the blood and soft tissue. Thereafter, the bone seeking radio pharmaceutical remains in areas of newly forming bone at the calcifying front.

 In a study by Kaplan et al 1975 observed that beagle dogs with moderate to advanced alveolar bone loss had a six times greater alveolar bone seeking radio pharmaceutical uptake [BSRU]compared to dogs without alveolar bone loss.

 Later it was used to monitor Tetracycline and NSAIDS on slowing periodontal disease progression and altering bone metabolism in 6 months [Jeffcoat et al 1980, 87].

The accuracy with the method was 83.5% to distinguish between teeth, which are active or not active.

 Findings indicated a highly significant association between BSRU and active bone loss with accuracy of 79 %.

Using this technique is promising for determining periodontal disease activity, but however, due to added radiation risk in patients, it is not currently applicable to clinical practice

Three-dimensional imaging in periodontal diagnosis Utilization of cone beam computed tomography

CBCT scanning has become a valuable imaging modality in periodontology as well as implantology.

For the detection of smallest osseous defects, CBCT can display the image in all its three dimensions by removing the disturbing anatomical structures and making it possible to evaluate each root and surrounding bone.

 In implant treatment, appropriate site or size can be chosen before placement, and osseointegration can be studied over a period of time. It is cheaper than CT, less bulky and generates low dosages of X-radiations. Patient radiation dose is 5 times lower than normal CT.

PRINCIPLES AND EVOLUTION OF CBCT

CBCT scanners utilize a two-dimensional detector. The first CBCT scanner ever to be built was built for angiography among other tasks at Mayo in 1982. Later, Fahrig et al., Wiesent et al., Saint- Felix et al., Ning et al., Schueler et al., and Kawata et al. have developed a CBCT CTA (Computed tomography angiography) system for angiographic imaging.

 Jaffray and Siewerdsen and Cho et al. have also developed a CBCT system for radiotherapy applications.

CBCT clinical systems that are both inexpensive and small enough to be used in operation theaters, medical and dental offices, emergency rooms, and intensive care.

 Four technological and application-specific factors have converged to make this possible.

1. First, compact and high-quality flat-panel detector arrays were developed.

2. Second, the computer power necessary for cone-beam image reconstruction has become widely available and is relatively inexpensive.

 3. Third, x-ray tubes necessary for cone-beam scanning are orders-of-magnitude that are less expensive than those required for conventional CT.

4. Fourth, by focusing on head/neck scanning only, one can eliminate the need for sub-second gantry rotation speeds that are needed for cardiac and thoracic imaging. This significantly reduces the complexity and cost of the gantry.

CBCT IMAGE PRODUCTION

CBCT machines scan patients in the following three possible positions: sitting, standing, or supine. The four components of CBCT image production are as follows: Acquisition configuration Image detection: Image reconstruction Image display

Advantages of CBCT
1. It has a rapid scan time as compared with panoramic radiography. 2. It gives complete 3D reconstruction and display from any angle. 3. Its beam collimation enables limitation of X-radiation to the area of interest. 4. Image accuracy produces images with submillimeter isotropic voxel resolution ranging from 0.4 mm to as low as 0.076 mm. 5. Reduced patient radiation dose (29477 Sv) as compared with conventional CT (approx. 2000 Sv). Patient radiation dose is five times lower than normal CT, as the exposure time is approximately 18 seconds, that is, one-seventh the amount compared with the conventional medical CT.

 6. CBCT units reconstruct the projection data to provide interrelational images in three orthogonal planes (axial, sagittal, and coronal). 7. Multiplanar reformation is possible by sectioning volumetric datasets nonorthogonally. 8. Multiplanar image can be thickened by increasing the number of adjacent voxels included in the display, referred to as ray sum. 9. 3D volume rendering is possible by direct or indirect technique. 10. The three positioning beams make patient positioning easy. Scout images enable even more accurate positioning. 11. Reduced image artifacts: CBCT projection geometry, together with fast acquisition time, results in a low level of metal artifact in primary and secondary reconstructions.

DISADVANTAGES
The only disadvantage is its cost.

But considering the enormous benefits, this cost effect can be overlooked.

Indications of CBCT
1. Evaluation of the jaw bones which includes the following: Pathology Bony and soft tissue lesions Periodontal assessment Endodontic assessment Alveolar ridge resorption; Recognition of fractures and structural maxillofacial deformities; Assessment of the inferior alveolar nerve before extraction of mandibular third molar impactions; Orthodontic evaluation3D cephalometry; Temporomandibular joint evaluation; and Implant placement and evaluation

 2. Airway assessment 3. Whenever there is need for 3D reconstructions In short, CBCT is ideally suited for high-quality and affordable CT scanning of the head and neck in dentomaxillofacial applications.

PERIODONTAL APPLICATIONS
The first reported applications of CBCT in periodontology were for diagnostic- and treatment-outcome evaluations of periodontitis ------Tynd all DA, Ito K.

CBCT in assessment of PDL space ----Ozmeric N. CBCT for periodontal defect measurements. Soft tissue CBCT for the measurement of gingival tissue and the dimensions of the dentogingival unit. CBCT precision in alveolar bone density measurement CBCT for diagnostic imaging for the implant patient

 1. IOPA radiograph of mandibular molar region 2. CBCT images of mandibular first molar showing the marginal bone defect and the precisely assessed degree of bone loss. In the upper right corner is a 3D image based on the radiographic volume data

Cone beam geometry

3D volume image of the dental and craniofacial complex

References
Carranzas clinical periodontology 10th edition. Steven I. Gold; Diagnostic techniques in periodontology: a historical review: Periodontology 2000, Vol. 7, 1995, 9-21. Xiaoming Xiang; An Update on Novel NonInvasive Approaches for Periodontal Diagnosis : J Periodontol 2010;81:186-198. Michael S. Reddy; The Use of Periodontal Probes and Radiographs in Clinical Trials of Diagnostic Tests: Ann Periodontol1997;2:113122.

References
Ira B. Lamster & John T. Grbic; Diagnosis of periodontal disease based on analysis of the host response: Periodontology 2000, Vol. 7, 1995, 83-99. Position Paper Diagnosis of Periodontal Diseases; J Periodontol 2003;74:1237-1247. James D. Beck; Issues in assessment of diagnostic tests and risk for periodontal diseases: Periodontology 2000, Vol. 7, 1995, 100-1 08. Joseph J. Zambon & Violeti. Haraszthy; the laboratory diagnosis of periodontal infections: Periodontology 2000, Val. 7, 1995, 69-82.

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