The use of cone-beam computed tomography in dentistry : An advisory statement from the American Dental Association Council on Scientific

Affairs The American Dental Association Council on Scientific Affairs JADA 2012;143(8):899-902 The following resources related to this article are available online at jada.ada.org ( this information is current as of July 7, 2013):
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The use of cone-beam computed tomography in dentistry

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An advisory statement from the American Dental Association Council on Scientific Affairs
The American Dental Association Council on Scientific Affairs

he emergence of cone-beam computed tomography (CBCT) has expanded the field of oral and maxillofacial radiology. CBCT imaging provides three-dimensional volumetric data construction of dental and associated maxillofacial structures with isotropic resolution and high dimensional accuracy. A CBCT scanner uses a collimated x-ray source that produces a cone- or pyramid-shaped beam of xradiation, which makes a single full or partial circular revolution around the patient, producing a sequence of discrete planar projection images using a digital detector. These two-dimensional images are reconstructed into a three-dimensional volume that can be viewed in a variety of ways, including cross-sectional images and volume renderings of the oral anatomy. Although CBCT units produce a higher radiation dose than one would receive from a single traditional dental radiograph, the radiation dose delivered typically is less than that produced during a medical multichannel computed tomographic scan. CBCT radiation doses also vary widely according to the device used, x-ray energy and filtration, tolerance for image noise and motion artifacts, and the size of the imaging area (field of view [FOV]) that is used to acquire volumetric data1-3 (Table,2,4,5 page 901). Since CBCT devices were introduced commercially in the United States in 2001, dentists have come to use the technology in increasing numbers. Yet,

AB STRACT
Background and Overview. The American Dental Association Council on Scientific Affairs (CSA) promotes safe use of conebeam computed tomography (CBCT) and appropriate professional justification of CBCT imaging procedures. The CSA reviewed the current research literature to develop collaborative guidance regarding the use of CBCT in dentistry with input from a broad group of stakeholder organizations. The Councils principles for CBCT safety may be applied to any number of potential dental CBCT imaging applications. Practice Implications. As with other radiographic modalities, CBCT imaging should be used only after a review of the patients health and imaging history and the completion of a thorough clinical examination. Dental practitioners should prescribe CBCT imaging only when they expect that the diagnostic yield will benefit patient care, enhance patient safety or improve clinical outcomes significantly. Key Words. Radiation protection; professional practice; dental radiography; cone-beam computed tomography. JADA 2012;143(8):899-902.

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although CBCT technologies have advanced rapidly across time, concerns have been expressed about whether the information acquired with CBCT imaging warrants the additional exposure risk, as well as about the level of training, education and experience required to interpret the CBCT data set.1 To provide guidance on CBCT imaging, national and international groups have prepared basic principles,1 position statements6,7 and professional guidelines for CBCT use.4,8 Recommendations for adequate operator education regarding use and interpretation of CBCT imaging also have been published.1,6 In addition, CBCT guidance documents are being developed by dental specialty organizations.9 As with any clinical guidance regarding the acquisition of diagnostic information, dentists must keep in mind their primary ethical obligation to protect patients from harm. Consistent with its mission to serve as a primary resource on the science of dentistry, the ADA Council on Scientific Affairs (CSA) reviewed the current science, guidance and other resources available from professional organizations to prepare this advisory statement of principles for the safe use of CBCT in dentistry. The Council then sought comments and input from a range of stakeholder organizations (listed in the acknowledgments at the end of this article) to develop this collaborative guidance statement for the profession.
PRINCIPLES FOR THE SAFE USE OF DENTAL AND MAXILLOFACIAL CONEBEAM COMPUTED TOMOGRAPHY

The Council recommends adherence to the following principles for the safe and appropriate use of CBCT in clinical practice. dAs with other radiographic modalities, CBCT imaging should be used only after a review of the patients health and imaging history and completion of a thorough clinical examination. dIn accordance with the National Council on Radiation Protection & Measurements10 (NCRPs) Report No. 145 and standard selection criteria for dental radiographs,11 clinicians should perform radiographic imaging, including CBCT, only after professional justification that the potential clinical benefits will outweigh the risks associated with exposure to ionizing radiation. All radiographic examinations should be indicated clinically and justified appropriately, and such examinations should not be performed for screening purposes. Additional considerations should be weighed prior to the exposure of children and adolescents. These patients are more radiosensitive (that is, their cancer risk
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per unit dose of ionizing radiation is higher), and they have a longer lifetime risk of developing radiation-induced cancers.12,13 dThe clinician should prescribe traditional dental radiographs and CBCT scans only when he or she expects that the diagnostic yield will benefit patient care, enhance patient safety, significantly improve clinical outcomes or all of these. dCBCT should be considered as an adjunct to standard oral imaging modalities. CBCT may supplement or replace conventional (twodimensional or panoramic) dental radiography for the diagnosis, monitoring and treatment of oral disease or the management of oral conditions when, in the clinicians decision-making process, he or she determines that oral anatomical structures of interest may not be captured adequately by means of conventional radiography. dIn accordance with the as-low-as-reasonablyachievable (ALARA) principle, radiation dose for dental patients should be optimized to achieve the lowest practical level to address a specific clinical situation. (Authors note: Dose optimization means delivering a radiation dose to the organs and tissues of clinical interest no greater than that required for adequate imaging and minimizing the dose to other structures. The patients radiation dose is considered to be optimized when imaging is performed with the least amount of radiation required to provide adequate image quality. The goal of every imaging procedure is to provide images adequate for the clinical purpose. What constitutes adequate image quality depends on the modality being used and the clinical question being asked.) The clinician should limit the radiation dose for CBCT scans by optimizing image quality, using the smallest FOV necessary for imaging a specific anatomical area of interest and using the lowest combination of tube output and scan time (in milliamperes) consistent with adequate image noise content and motion artifact. dCBCT operators should take every precaution to reduce radiation dose and ensure the patients safety during CBCT imaging. The use of thyroid collars and lead aprons is recommended in the NCRPs10 radiation safety guidABBREVIATION KEY. ADA: American Dental Association. ALARA: As low as reasonably achievable. CBCT: Cone-beam computed tomography. CSA: Council on Scientific Affairs. FOV: Field of view. NCRP: National Council on Radiation Protection & Measurements.

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TABLE ance for the dental profession. However, Effective dose estimates for common dental it is neither possible radiographic examinations and cone-beam nor desirable to use these protective computed tomographic (CBCT) imaging.* devices in all clinical IMAGING TECHNIQUE EFFECTIVE DOSE situations, especially Conventional Radiography in cases in which the Four-image posterior bitewings with photo-stimulable phosphor (PSP) 5.0 collar or apron may or F-speed film and rectangular collimation obstruct the area of Panoramic radiograph with charge-coupled device 3.0-24.3 Cephalometric radiograph, posteroanterior or lateral with PSP 5.1-5.6 interest. Protective Full-mouth radiographs thyroid collars and PSP storage or F-speed film and rectangular collimation 34.9 lead aprons should be With With PSP or F-speed film and round collimation 170.7 used when they will CBCT not interfere with the Dentoalveolar CBCT (small and medium field of view [FOV]) 11-674 (61) examination. Maxillofacial CBCT (large FOV) 30-1073 (87) dA CBCT exami* Estimates for adult patients based on data from Pauwels and colleagues, The SEDENTEXCT Project nation should be preand Ludlow and colleagues. Measured in microsieverts. scribed by a dentist Median values for effective dose provided parenthetically. who has appropriate training and education in CBCT imaging, including an underdDentists must abide by applicable federal and standing of the significance of CBCT selection state regulations in the provision of dental and imaging findings. imaging modalities. This includes following regdCBCT images of the oral and maxillofacial ulations or guidance to ensure a safe working structures that are the subject of the CBCT environment for both the staff and the public in examination should be evaluated by a dentist relation to CBCT equipment and other sources with appropriate training and education in of ionizing radiation. CBCT unit operators CBCT interpretation. (Authors note: Estabshould contact state and local radiation control lishing formal standards for CBCT training and programs to verify any additional requirements education is beyond the scope of this CSA advifor operation of CBCT, including applicable sory statement. The Council will share the requirements for licensure or accreditation. statement with the Commission on Dental dDentists should use professional judgment in Accreditation and other educational groups for the prescription and performance of CBCT further consideration.) examinations by consulting recommendations dRegardless of the primary purpose for the from available CBCT guidelines and by considselection of CBCT, the complete image data set ering the specific clinical situation and needs of must be interpreted by an appropriately qualithe individual patient. Given the ongoing develfied health care provider (such as a dentist or a opment and research in this technology, dentists physician). The prescribing clinician should should stay abreast of the scientific literature receive a thorough radiological report. If the and apply an evidence- and science-based prescriber also interprets the CBCT images, he approach to the use of CBCT. or she should enter the findings into the patient dThis advisory statement calls for appropriate record and communicate them appropriately to agencies within the ADA and the dental commuthe patient or, if the patient is a minor, to the nity at large to develop and implement recompatients parent or legal guardian. mendations and criteria for adequate CBCT dDental practitioners who use CBCT devices training and education of dentists or other must receive appropriate training and education CBCT unit operators. These recommendations in the safe use of CBCT imaging systems. Alshould include but not be limited to patient though there may be instances in which trainevaluation, radiation protection, selection of ing provided by vendors of CBCT systems is apappropriate CBCT imaging parameters, perpropriate, dental practitioners should consider formance of the CBCT examination and image the source of the information concerning radiation interpretation. The recommendations also must safety. The Council encourages CBCT operators include requirements for predoctoral dental to participate in continuing education courses to education programs and for continuing educamaintain adequate knowledge regarding radiation coursework and training. tion protection in the dental care setting. dFacilities considering the installation of
2 4 5

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American Academy of Oral and Maxillofacial Radiology; the American Academy of Pediatric Dentistry; the American Academy of Periodontology; the American Association of Endodontists; the American Association of Oral and Maxillofacial Surgeons; the American Association of Orthodontists; the American Association of Physicists in Medicine; the Conference of Radiation Control Program Directors; the National Council on Radiation Protection & Measurements; and the U.S. Food and Drug Administration. 1. Horner K, Islam M, Flygare L, Tsiklakis K, Whaites EJ. Basic principles for use of dental cone beam computed tomography: consensus guidelines of the European Academy of Dental and Maxillofacial Radiology. Dentomaxillofac Radiol 2009;38(4):187-195. 2. Pauwels R, Beinsberger J, Collaert B, et al; SEDENTEXCT Project Consortium. Effective dose range for dental cone beam computed tomography scanners. Eur J Radiol 2012;81(2):267-271. 3. Ludlow JB, Ivanovic M. Comparative dosimetry of dental CBCT devices and 64-slice CT for oral and maxillofacial radiology. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2008;106(1):106-114. 4. The SEDENTEXCT Project. Radiation Protection: Cone Beam CT for Dental and Maxillofacial Radiology: Evidence Based Guidelines 2011 (v2.0 Final). www.sedentexct.eu/files/guidelines_final.pdf. Accessed May 11, 2012. 5. Ludlow JB, Davies-Ludlow LE, White SC. Patient risk related to common dental radiographic examinations: the impact of 2007 International Commission on Radiological Protection recommendations regarding dose calculation. JADA 2008;139(9):1237-1243. 6. Carter L, Farman AG, Geist J, et al; American Academy of Oral and Maxillofacial Radiology. American Academy of Oral and Maxillofacial Radiology executive opinion statement on performing and interpreting diagnostic cone beam computed tomography. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2008;106(4):561-562. 7. Joint Position Statement of the American Association of Endodontists and the American Academy of Oral and Maxillofacial Radiology. Use of cone-beam computed tomography in endodontics. www.aaomr.org/resource/resmgr/Docs/AAOMR-AAE_postition_ paper_CB.pdf. Accessed July 10, 2012. 8. Academy of Osseointegration. 2010 guidelines of the Academy of Osseointegration for the provision of dental implants and associated patient care. Int J Oral Maxillofac Implants 2010;25(3):620-627. 9. Scarfe WC. All that glitters is not gold: standards for conebeam computerized tomographic imaging (published online ahead of print Feb. 3, 2011). Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2011;111(4):402-408. doi:10.1016/j.tripleo.2011.01.006. 10. National Council on Radiation Protection & Measurements. Radiation Protection in Dentistry (Report No. 145). Bethesda, Md.: NRCP Publications; 2003. 11. American Dental Association; U.S. Department of Health and Human Services. The Selection of Patients for Dental Radiographic Examinations. Chicago: American Dental Association; 2004. www.ada.org/sections/professionalResources/pdfs/ topics_radiography_examinations.pdf. Accessed May 11, 2012. 12. National Research Council of The National Academies, Committee to Assess Health Risks from Exposure to Low Levels of Ionizing Radiation, Board of Radiation Effects Research, Division on Earth and Life Studies. 2006. Health Risks From Exposure to Low Levels of Ionizing Radiation: BEIR VII phase 2. Washington: National Academy of Sciences, National Academies Press; 2006. 13. International Commission on Radiological Protection. The 2007 Recommendations of the International Commission on Radiological Protection (publication 103). Ann ICRP 2007;37(2-4):1-332. 14. National Council on Radiation Protection & Measurements. Structural Shielding Design for Medical Imaging Facilities (Report No. 147). Bethesda, Md.: NRCP Publications; 2004.

CBCT devices should consult a health physicist (or other qualified expert) to perform a shielding analysis based on NCRP reports 145 and 147.10,14 dFacilities using CBCT systems should consult a health physicist (or other qualified expert) to perform equipment performance and compliance evaluations initially at installation and then follow a schedule in compliance with local, state and federal requirements. The Council recommends that a performance evaluation be completed at least annually. The evaluations should include patient dose estimation to assist the facility with patient dose management. dStaffs of facilities using CBCT should establish a quality control program. This program can be based on the manufacturers recommendations or can be established, implemented and monitored by a qualified expert.
SUMMARY

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CBCT technologies offer an advanced point-ofcare imaging modality that clinicians should use selectively as an adjunct to conventional dental radiography. The selection of CBCT for dental and maxillofacial imaging should be based on professional judgment in accordance with the best available scientific evidence, weighing potential patient benefits against the risks associated with the level of radiation dose. Clinicians must apply the ALARA principle in protecting patients and staff during the acquisition of CBCT images. This includes appropriate justification of CBCT use, optimizing technical factors, using the smallest FOV necessary for diagnostic purposes and using appropriate personal protective shielding. I
Disclosure. Members of the American Dental Association Council on Scientific Affairs (CSA) are required to maintain a current conflict-of-interest disclosure to participate in CSA activities. No potential conflicts of interest relevant to this statement were reported. The American Dental Association (ADA) Council on Scientific Affairs gratefully acknowledges Dr. John Ludlow, professor, School of Dentistry, University of North Carolina, Chapel Hill, and Dr. Sharon Brooks, professor emerita, School of Dentistry, University of Michigan, Ann Arbor, for their assistance in finalizing this advisory statement. The ADA expresses its appreciation to the following organizations for their significant contributions to the statement: the American Academy of Oral and Maxillofacial Pathology; the

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