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Dental CBCT Evidence Based Guideline 2012 European Commission
CBCT in DentistryEvidence Based Guideline Summary as Per european Union 2012
Justification and referral criteria1: All CBCT examinations must be justifiedon an individual basis by demonstratingthat the potential benefits to the patientsoutweigh the potential risks. CBCTexaminations should potentially add newinformation to aid the patient’smanagement. A record of the Justificationprocess must be maintained for eachpatient.
referral criteria2: CBCT should not be selected unless ahistory and clinical examination have beenperformed. “Routine” or “screening”imaging is unacceptable practice.3: When referring a patient for a CBCTexamination, the referring dentist mustsupply sufficient clinical information(patient history and results of examination)to allow the CBCT Practitioner to performthe Justification process.
Impacted Tooth4: For the localised assessment of animpacted tooth (including consideration ofresorption of an adjacent tooth) where thecurrent imaging method of choice isMSCT, CBCT may be preferred becauseof reduced radiation dose.
Impacted Tooth5: CBCT may be indicated for the localisedassessment of an impacted tooth(including consideration of resorption of anadjacent tooth) where the current imagingmethod of choice is conventional dentalradiography and when the informationcannot be obtained adequately by lowerdose conventional (traditional)radiography.
Impacted Tooth6: For the localised assessment of animpacted tooth (including consideration ofresorption of an adjacent tooth), thesmallest volume size compatible with thesituation should be selected because ofreduced radiation dose. The use of CBCTunits offering only large volumes(craniofacial CBCT) requires very carefuljustification and is generally discouraged.
Cleft Palate7: Where the current imaging method ofchoice for the assessment of cleft palate isMSCT, CBCT may be preferred if radiationdose is lower. The smallest volume sizecompatible with the situation should beselected because of reduced radiationdose.
Orthodontics8: CBCT is not normally indicated for planning theplacement of temporary anchorage devices inorthodontics.9: Large volume CBCT should not be used routinelyfor orthodontic diagnosis.10: For complex cases of skeletal abnormality,particularly those requiring combinedorthodontic/surgical management, large volumeCBCT may be justified in planning the definitiveprocedure, particularly where MSCT is the currentimaging method of choice.
Orthodontics11: Research is needed to define robustguidance on clinical selection for largevolume CBCT in orthodontics, based uponquantification of benefit to patient outcome.
Caries and Periodontal Tissues 12: CBCT is not indicated as a method of caries detection and diagnosis. 13: CBCT is not indicated as a routine method of imaging periodontal bone support.
Caries and Periodontal Tissues 14: Limited volume, high resolution CBCT may be indicated in selected cases of infra-bony defects and furcation lesions, where clinical and conventional radiographic examinations do not provide the information needed for management. 15: Where CBCT images include the teeth, care should be taken to check for periodontal bone levels when performing a clinical evaluation (report).
Endodontics16: CBCT is not indicated as a standardmethod for identification of periapicalpathosis.17: Limited volume, high resolution CBCTmay be indicated for periapicalassessment, in selected cases, whenconventional radiographs give a negativefinding when there are contradictorypositive clinical signs and symptoms.
Endodontics18: Where CBCT images include the teeth,care should be taken to check forperiapical disease when performing aclinical evaluation (report).19: CBCT is not indicated as a standardmethod for demonstration of root canalanatomy.
Endodontics20: Limited volume, high resolution CBCT may beindicated, for selected cases where conventionalintraoral radiographs provide information on rootcanal anatomy which is equivocal or inadequate forplanning treatment, most probably in multi-rootedteeth.21: Limited volume, high resolution CBCT may beindicated for selected cases when planning surgicalendodontic procedures. The decision should bebased upon potential complicating factors, such asthe proximity of important anatomical structures.
Endodontics22: Limited volume, high resolution CBCT may beindicated in selected cases of suspected, orestablished, inflammatory root resorption or internalresorption, where three dimensional information islikely to alter the management or prognosis of thetooth.23: Limited volume, high resolution CBCT may bejustifiable for selected cases, where endodontictreatment is complicated by concurrent factors,such as resorption lesions, combinedperiodontal/endodontic lesions, perforations andatypical pulp anatomy.
Dental Trauma24: Limited volume, high resolution CBCTis indicated in the assessment of dentaltrauma (suspected root fracture) inselected cases, where conventionalintraoral radiographs provide inadequateinformation for treatment planning.
Mandibular Third Molar Removal 25: Where conventional radiographs suggest a direct inter-relationship between a mandibular third molar and the mandibular canal, and when a decision to perform surgical removal has been made, CBCT may be indicated.
Impacted Tooth26: CBCT may be indicated for pre-surgical assessment of an unerupted toothin selected cases where conventionalradiographs fail to provide the informationrequired.
Implant27: CBCT is indicated for cross-sectionalimaging prior to implant placement as analternative to existing cross-sectionaltechniques where the radiation dose ofCBCT is shown to be lower.
Implant28: For cross-sectional imaging prior toimplant placement, the advantage ofCBCT with adjustable fields of view,compared with MSCT, becomes greaterwhere the region of interest is a localisedpart of the jaws, as a similar sized field ofview can be used.
Soft Tissue Assessment29: Where it is likely that evaluation of softtissues will be required as part of thepatient’s radiological assessment, theappropriate initial imaging should beMSCT or MR, rather than CBCT.
Oral Cancer Bony Invasion30: Limited volume, high resolution CBCTmay be indicated for evaluation of bonyinvasion of the jaws CBCT by oralcarcinoma when the initial imagingmodality used for diagnosis and staging(MR or MSCT) does not providesatisfactory information.
Fracture31: For maxillofacial fracture assessment,where cross-sectional imaging is judged tobe necessary, CBCT may be indicated asan alternative imaging modality to MSCTwhere radiation dose is shown to be lowerand soft tissue detail is not required.
Orthognathic Surgery32: CBCT is indicated where boneinformation is required, in orthognathicsurgery planning, for obtaining three-dimensional datasets of the craniofacialskeleton.
TMJ33: Where the existing imaging modalityfor examination of the TMJ is MSCT,CBCT is indicated as an alternative whereradiation dose is shown to be lower.
the reduction of radiation risk to patients1: X-ray tube voltage and tube current-exposure time product should beadjustable on CBCT equipment and mustbe optimised during use according to theclinical purpose of the examination, ideallyby setting protocols with the input of amedical physics expert.
Volume Size2: Multipurpose dental CBCT equipmentshould offer a choice of volume sizes andexaminations must use the smallest that iscompatible with the clinical situation if thisprovides less radiation dose to the patient.
Optimisation3: Research studies on optimisation offiltration for dental CBCT units should beperformed.4: Dental CBCT units equipped with eitherflat panel detectors or image intensifiersneed to be optimised in terms of dosereduction before use.
Voxel Size5: Multipurpose dental CBCT equipmentshould offer a choice of voxel sizes andexaminations should use the largest voxelsize (lowest dose) consistent withacceptable diagnostic accuracy.
Projection6: Research studies should be performedto assess further the effect of the numberof projections on image quality andradiation dose.
Shielding7: Shielding devices could be used toreduce doses to the thyroid gland where itlies close to the primary beam. Care isneeded in positioning so that repeatexposure is not required. Further researchis needed on effectiveness of such devicesin dose reduction.
and quality assurance1: Published equipment performancecriteria should be regularly reviewed andrevised as greater experience is acquiredin testing dental CBCT units.
Testing2: Testing of dental CBCT should include acritical examination and detailedacceptance and commissioning tests whenequipment is new and routine teststhroughout the life of the equipment.Testing should follow publishedrecommendations and a medical physicsexpert should be involved.
Dose-Area Product (DAP) CBCT3: Manufacturers of dentalequipment should provide a read-out ofDose-Area Product (DAP) after eachexposure.4: Until further audit data is published, thepanel recommend the adoption of anachievable Dose Area Product of 250 mGysq.cmfor CBCT imaging for the placementof an upper first molar implant in astandard adult patient.
Image Quality5: Assessment of the clinical quality ofimages should be a part of a qualityassurance programme for CBCT.6: Establishments carrying out CBCTexaminations should perform rejectanalysis, either prospectively or as part ofretrospective clinical audit, at intervals nogreater than once every six months.
Audit7: As a minimum target, no greater than5% of CBCT examinations should beclassified as “unacceptable”. The aimshould be to reduce the proportion ofunacceptable examinations by 50% ineach successive audit cycle.8: Image quality criteria should bedeveloped for dental CBCT, ideally at theEuropean level.
Staff protection1: It is essential that a qualified expert isconsulted over the installation and use ofCBCT to ensure that staff dose is as lowas reasonably achievable and that allrelevant national requirements are met.2: CBCT equipment should be installed ina protected enclosure and the whole of theenclosure designated a Controlled Area.
Dosimetry3: Detailed information on the dose due toscattered radiation should be obtained toinform decisions about shieldingrequirements.4: The provision of Personal Monitoringshould be considered.
Training1: All those involved with CBCT musthave received adequate theoretical andpractical training for the purpose ofradiological practices and relevantcompetence in radiation protection.2: Continuing education and training afterqualification are required, particularly whennew CBCT equipment or facilities areadopted.
Additional Training3: Dentists and dental specialistsresponsible for CBCT facilities who havenot previously received “adequatetheoretical and practical training” shouldundergo a period of additional theoreticaland practical training that has beenvalidated by an academic institution(University or equivalent). Where nationalspecialist qualifications in Dental andMaxillofacial Radiology exist, the designand delivery of CBCT training programmesshould involve a Dental and Maxillofacial
Further Training4: CBCT applications specialists andagents of manufacturers and suppliers ofCBCT equipment who provide informationand training to clinical staff should obtainrelevant training in radiation protection andoptimization.
Adopted From EUROPEAN COMMISSION RADIATION PROTECTION N° 172CONE BEAM CT FOR DENTAL AND MAXILLOFACIAL RADIOLOGY Evidence Based Guidelines Directorate-General for Energy Directorate D — Nuclear Energy Unit D4 — Radiation Protection 2012