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Question: Is 3D imaging the new standard of care?
“Standard of care” is a legal term, not a dental one. The standard of care is continually evolving and is determined by the courts, not a dentist. The definition of standard of care is also not static because there are constantly updates in materials, procedures, and court rulings. A basic definition of standard of care is “a dentist is under a duty to use that degree of care and skill which is expected of a reasonably competent dentist acting in the same or similar circumstances.” This statement can be interpreted to mean that depending on your geographic location, the “standard” may be different. A basic statement of standard of care is “A dentist is under a duty to use that degree of care and skill which is expected of a reasonably competent dentist acting in the same or similar circumstances.” So depending on your location, the standard may be different.
3-D imaging is still not in generalized use in US dental offices. No matter what modality a dentist decides to introduce to their patients, the dentist must be must be reasonably prudent and competent in its use. The vast majority of dentists at this time would need additional education to read a 3-D scan. Just as dentists were taught radiology in dental school to diagnose pathology, they can be taught the same in 3-D cone beam imaging. The ability to learn to read cone-beam scans is within the scope of most dentists. The dentist must be able to know normal anatomy from pathologic anatomy, and when pathology is identified they could make the appropriate referrals to have the scan read by an oral radiologist. Failure to diagnose pathology is a concern when reading 3-D scans for those not well versed in its use.
I believe that 3-D imaging is not the standard of care at this time but this type of imaging is progressing rapidly to the point that it will be the standard of care in the not-too-distant future for certain dental procedures, such as implant placement treatment planning and third-molar extractions.
Since I emphatically stated at the Dental Clinics of North America in 2008 that, “dentists and dental specialists will never completely replace some conventional imaging techniques such as intraoral and panoramic with CBVT,” I have not changed my opinion or my mind. To date, I have read more than 11,000 CBCT scans for occult pathology for cone-beam owners. I lecture nationally and worldwide in the subject. I am as enthusiastic as anyone about the technology. However, simply put, it is just another imaging modality available to dental practitioners. I would have to ask the additional question: “The standard of care…for what?” In my opinion, there is no one-size-
In their enthusiasm, manufacturers will tell potential buyers that they could replace all of their x-rays with CBCT. This will not happen. You cannot justify a CBCT examination, despite its low dose even when a suitable small field of view and suitable exposure factors are used, to examine a 9-year-old for the permanent successors to the primary dentition when a high-resolution, much lower-dose digital panoramic would do the job. If, however, the child had an anomaly such as a supernumerary discovered on the initial panoramic, CBCT imaging could be used as a follow-up examination. If the clinician only had a CBCT machine, and was only interested in reviewing a reconstructed panoramic type image to determine the location and development of the successor teeth, the dose—as low as it is from some CBCT machines—would still be higher than the panoramic. It would be more prudent and cause less potential harm to the patient to simply do a panoramic examination.
In my opinion, CBCT imaging is more appropriate for: third-molar maxillary and/or mandibular extractions; implant site assessment; airway assessment for obstructive sleep-apnea patients; assessment of suspected lesions/disorders of the temporomandibular joint complex; difficult endodontic procedures (after clinical and conventional radiographic assessment); orthognathic and trauma surgery; adult orthodontic case assessment; paranasal sinus evaluation when clinical and/or other radiographic imaging suggests a problem; and preoperative assessment of odontogenic or non-odontogenic lesions discovered on other radiographs.
From this list one can see that there are many areas where CBCT imaging could become the standard of care. These low-dose, dentally specific, 2-D and 3-D image data sets have already proven more effective than many conventional dental radiographic modalities. However, one should never be of the opinion that a single imaging modality would be appropriate for every diagnostic task. This is the case in medicine and should not be different for the dental profession.
Allen Ali Nasseh, DDS
This technology has helped dental surgeons see beyond the available information provided by a conventional radiograph and gain access to diagnostic information that was only available until recently through expensive medical imagery. As additional information is a significant factor for improving the treatment plan and preparing for potential treatment risks, there is no doubt that this additional tool has been a blessing for the dental surgeon. However, the question of whether this tool should be the standard of care is an entirely different proposition as the term “standard of care” creates legal implications for daily practice. For instance, if a special clinical practice is deemed the standard of care through a state act or common law, then anyone not using it for any given case, whether deemed necessary or not by the clinician’s judgment is automatically performing an act of negligence subject to malpractice litigation.
It is also clear that despite their usefulness, cone-beam radiographs are not indicated 100% of the time when preparing for surgery. In endodontic therapy, although cone-beam radiography has been a useful tool to diagnose and triage surgical vs. re-treatment cases and make some diagnostic predictions, I strongly discourage indiscriminate use of this technology on every patient in hope of gaining additional information. The extra radiation and the additional cost will not only increase the overall healthcare bill on the patient, it will expose them to harmful radiation, which although in a small dose, is cumulative and may not be beneficial to every patient. All astute healthcare practitioners must constantly balance the risk of surgery against the risk of gaining additional information for performing that surgery. 3-D cone-beam radiography is a great addition to the armamentarium we use as clinicians, but considering them the standard of care has legal limitations that this relatively nascent technology will have to wait to prove beyond a shadow of doubt.
About the Authors
Martin Jablow, DMD | Dr. Jablow is a private practitioner in Woodbridge, New Jersey.
Dale A. Miles BA, DDS, MS, FRCD(c) | Dr. Miles is the chief executive officer of Interactive Diagnostic Systems, Inc., and has a private practice in Fountain Hills, Arizona.
Allen Ali Nasseh, DDS, MMSc | Dr. Nasseh is a private practitioner in Boston, Massachusetts, and a clinical instructor in the Department of Restorative Dentistry and Biomaterial Sciences at Harvard University School of Dental Medicine.