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According To “Dr. Wo” Wm. Randol Womack, DDS Editorial Director, Orthotown Magazine

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The Twain Shall Meet
CBCT and its Impact on Orthodontic Standard of Care
by Wm. Randol Womack, DDS, Board Certified Orthodontist
Editorial Director, Orthotown Magazine

Since the early issues of Orthotown Magazine, cone beam computed tomography (CBCT) or cone beam volumetric imaging (CBVI) has been featured in numerous articles. If you visit Orthotown.com and search for CBCT you will find more than four pages of listings.

These articles have been authored by leaders in orthodontics and oral maxillofacial radiology. You will also find quotes from some of the "experts" in the legal issues surrounding this technology. We have kept this topic at the forefront because we believe it is developing into a critical issue that will change the standard of care in orthodontics. When this happens, it will affect the professional, ethical and economic decisions orthodontists make in running their practices, and the way orthodontics is taught in our resident programs. At the present time, it is impossible to know when this change in the standard of care will be formally recognized by the American Association of Orthodontists (AAO) or state boards. None of the "experts" who I have interviewed and consulted, or publications I have read can pinpoint this happening, but they all agree… it is happening!

I took the liberty to review what we have already published about CBCT and copied a few excerpts from key articles to review where we've come from and where we are now.

Of course, as with any technology, the "half-life" is not all that long and our digital pan/ceph is already being overshadowed by CBCT scans. So there is no sitting still or being satisfied in this hyperlinked world in which we practice. But that is really the exciting thing about orthodontics today. About the time you feel comfortable – BAM – something new and better comes across your desk in some magazine. When will it ever stop? Not in my lifetime, that's for sure – and that's good!
-Dr. Randy Womack, "According to Dr. Wo," November 2008

One of the more recent and exciting developments is the ability to superimpose two data volumes. This feature could provide new insights into growth, development, treatment effects and outcomes. In addition, it stands to conclusively answer some of the controversies in orthodontics regarding specific treatment claims and effects.
-Dr. James Mah, "Evolution of Imaging Technologies in Orthodontics," September 2009

Owning these machines is not like a button-pushing exercise and out pops a perfect image every time that answers all questions. These machines have a lot of variables which you can tweak and play with but you have to know what you're doing right up front. It's kind of like playing a musical instrument – everybody can buy one, but not everybody can play one.
-Dr. David Hatcher, "Expert Opinions: CBCT and Orthodontics," September 2009

You will use this technology or the data from it. It will improve your practice, make your treatment decisions much easier, be better for the patient by reducing morbidity associated with some dental procedures, and will change your view of appropriate dental imaging. Do not wait. Get trained, get ready and get started!
-Dr. Dale Miles, "Expert Opinions: CBCT and Orthodontics," September 2009

What I see happening is that more and more orthodontists are simply going to train themselves. We believe at some point orthodontists can educate themselves enough to actually interpret the whole full-volume… I think if you are taking a full-volume scan, it is very nice to have a radiologist to comment. What we are finding is – in about four or five percent of our images – the radiologist finds some pathology.
-Dr. Bob Boyd, "Expert Opinions: CBCT and Orthodontics," September 2009

Now CBCT scanners have arrived and I think there will be a split in the way this is going to happen. The fellas that can't afford to pay for a CBCT scanner will send their patients to a lab for CBCT scans. But here's the rub. Obsolescence is going to rear its ugly head in about five years. Exponential growth of CBCT scanners with better resolution will appear about the time your old CBCT scanner is completely paid off. So is it better to use a laboratory where that guy has to buy a new scanner or is it better to have it in your office? …As I said to an orthodontic resident recently, "I envy you. I'm at the end of my orthodontic career and what you're going to experience in your next 40 years is totally different. You're going to be dealing with genetics and 3D analyses and ways of treating patients and obtaining growth information we've never even thought of." The new generation is going to have fun.
-Dr. Ron Redmond, "Expert Opinions: CBCT and Orthodontics," September 2009

The diagnostic benefits of using the cone beam have been dramatic. What is amazing to me is what I was not seeing in typical orthodontic diagnostic records. The clarity of the TMJ; airway from five different views; anomalies and pathology would never have been previously detected. …This technology is here to stay. It is especially helpful for those of us who lecture. It is taking some of the guesswork out of what is truly happening in our clinical treatment.
-Dr. Ron Roncone, "3D CBCT Imaging for Routine Use in Orthodontics," December 2009

Cone beam technology is evolving into the standard of care in the orthodontic practice. This field of view has affected my point of view on imaging. The scans have helped me to achieve some novel orthodontic results and have had such a positive impact on my practice that I couldn't imagine practicing without it.
-Dr. John Graham, "My Point of View on 3D's Field of View," April 2010

These snapshots from Orthotown Magazine articles give you a refresher on the invasion of CBCT into the practice of orthodontics. One of the immediate questions to be answered might be "Should CBCT scans be used on every patient?" More and more orthodontists are using CBCT as their primary source of patient records. It is an individual decision. Some orthodontists are selectively using CBCT scans for specific diagnostic issues. They might have their own machine or they might refer patients to a radiology facility. The following was recently printed in the PCSO Bulletin: "The PCSO initiated a resolution… about pressure on clinicians to routinely use CBCT scans for treatment planning. As a result the AAO House of Delegates decided to add to the 2008 AAO Clinical Practice Guidelines a statement that acknowledges the 'need' for CBCT scans in some patients but… it is not 'required' for orthodontic diagnosis and treatment planning." In my view this is merely tap dancing around the inevitable.

In the resident program where I teach part-time there have been concerns expressed about the radiation of CBCT scans, to the point that the use of CBCT scans for routine diagnosis (which has been the protocol for the past four years) is going to be modified and reduced. Consider the presentations at the recent Fourth International Congress on 3D Dental Imaging: Radiation effective dose comparisons showed that an i-Cat 8.9 second scan produced 36 microsieverts and a 5.0 second i-Cat scan produced 20 microsieverts. A digital panoramic can produce 4.7-26 microsieverts and ceph 2-7 microsieverts. The radiation difference between the methods of collecting orthodontic diagnostic records isn't significant but the difference in the diagnostic information collected with the two methods is staggering.

To quote Dr. John Graham from his article in this issue of Orthotown Magazine: "With my full-field-of-view scanner, in about nine seconds I have the benefit of true orthogonal images, panoramic, lateral cephalometric, frontal cephalometric, paranasal sinuses, TMJ and airway views."

Several educators with whom I have communicated say orthodontic residents need a thorough education on cone beam applications and interpretations in order to meet the evolving standard of care.

As for the profession in general, I would refer you to an article from the American Journal of Orthodontics and Dentofacial Orthopedics (AJO-DO: Vol 136, Number 4) by Riolo and Vaden who stated: "Our specialty has an obligation and a right to develop criteria and standards for care. As a professional group, we must provide quality standards and thus self-regulation. Our right to self-regulation will end when an outside agency provides all criteria for care for us."

Until a clear definition of the standard of care is established by the AAO (or state boards), these controversies will continue. I am concerned that nothing will be done in a timely manner by our National Organization to resolve these controversies. Future legal settlements will have the greatest influence on clarifying the standard of care relating to CBCT scans. What I truly fear is the day that a reputable and competent orthodontist is called into court over a cone beam issue and the case is won by the attorney who has the most convincing "expert witness."

I think you will find this issue of Orthotown Magazine one that you will want to keep handy to read again and again, if only for the cover story by Don Machen and John Graham, and also the feature article by Art Curley. I hope you have saved the past issues that focus on CBCT. If you haven't, you can always access them online at Orthotown.com and you can even print copies of articles to start a CBCT file.

Orthotown Magazine will continue to focus on CBCT and all the issues surrounding this technology. Continue to look to Orthotown Magazine for CBCT updates as they develop. I promise you… it is going to get really interesting!
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