Correction to: Diagnostic efficacy of cone beam computed tomography in paediatric dentistry: a systematic review.

In the original publication of the article the fifth author's name "A. Littlewood" was submitted as "A. Littewood" which was left unnoticed in the later stages. The correct name is as published in this erratum.

Diagnostic efficacy of cone beam computed tomography in paediatric dentistry: a systematic review.

PURPOSE: To determine in which clinical situations it is indicated or contra-indicated to prescribe cone beam computed tomography (CBCT) for paediatric patients. METHODS: Systematic review of in vivo paediatric research studies of diagnostic efficacy using CBCT, with supplementary searches for guideline documents on CBCT and for systematic reviews permitting inclusion of ex vivo and adult studies. RESULTS: After screening, 190 publications were included, mostly case studies. No systematic reviews were found of in vivo paediatric research. Fourteen studies of diagnostic efficacy were identified. The supplementary searches found 18 guideline documents relevant to the review and 26 systematic reviews. The diagnostic efficacy evidence on CBCT was diverse and often of limited quality. There was ex vivo evidence for diagnostic accuracy being greater using CBCT than radiographs for root fractures. The multiplanar capabilities of CBCT are advantageous when localising dental structures for surgical planning. Patient movement during scanning is more common in children which could reduce diagnostic efficacy. CONCLUSIONS: No strong recommendations on CBCT are possible, except that it should not be used as a primary diagnostic tool for caries. Guidelines on use of CBCT in the paediatric age group should be developed cautiously, taking into account the greater radiation risk and the higher economic costs compared with radiography. CBCT should only be used when adequate conventional radiographic examination has not answered the question for which imaging was required. Clinical research in paediatric patients is required at the higher levels of diagnostic efficacy of CBCT.

Best clinical practice guidance for prescribing dental radiographs in children and adolescents: an EAPD policy document.

BACKGROUND: The European Academy of Paediatric Dentistry (EAPD) proposes this best clinical practice guidance to help practitioners decide when and how to prescribe dental radiographs in children and adolescents. METHODS: Four expert working groups conducted each a systematic review of the literature. The main subjects were radiation protection, intraoral dental radiography (bitewing and periapical radiographs), panoramic radiography (PR) and cone-beam computed tomography (CBCT). In addition, three workshops were held during the corresponding EAPD Interim Seminar in Chania (Crete, Greece) in 2019. On the basis of the identified evidence, all invited experts presented their findings and during the workshops aspects of clinical relevance were discussed. RESULTS: Several clinical-based recommendations and statements were agreed upon. CONCLUSION: There is no or low-grade evidence about the efficacy of dental radiographic examinations in young populations. The given recommendations and rationales should be understood as best clinical practice guidance. It is essential to respect the radiological principles of an individualized and patient-specific justification. When a dental radiograph is required, its application needs to be optimized, aiming at limiting the patient's exposure to ionising radiation according to the ALADAIP principle (As Low As Diagnostically Achievable being Indication-oriented and Patient-specific).

The use of localised CBCT to image inflammatory collateral cysts: a retrospective case series demonstrating clinical and radiographic features.

INTRODUCTION: Inflammatory collateral cysts are uncommon cysts primarily affecting first permanent molars during their eruption. There are diagnostic challenges that can be overcome with CBCT imaging. However, given the paediatric age group for this condition, there are patient cooperation and radiation dose factors to consider when justifying the scan. The aim of this case series study is to illustrate the value of CBCT in imaging and diagnosing inflammatory collateral cysts in paediatric patients, to highlight the need for a multidisciplinary approach for this uncommon pathological condition and to review the relevant literature. CASE SERIES DESCRIPTION AND RESULTS: We present three patients aged between 6 and 11 years of age with inflammatory collateral cysts affecting their first or second permanent molars for which CBCT imaging was utilised. All patients underwent cyst enucleation with preservation or extraction of affected teeth under general anaesthesia. DISCUSSION: Inflammatory collateral cysts are likely to be under reported given their indistinct clinical features and radiological signs. Conventional planar radiographs may not reveal this lesions size and full extent. CBCT overcomes these limitations; however, careful assessment of patient cooperation is needed and a low-dose protocol should be used. CONCLUSIONS: CBCT can provide useful imaging information which is difficult to obtain using conventional radiography, especially in cases where an inflammatory collateral cyst is suspected.

Guidelines on radiographic imaging as part of root canal treatment: a systematic review with a focus on review imaging after treatment.

AIM: To identify guidelines on endodontics which make recommendations relating to post-root canal treatment radiological review imaging, to make an objective assessment of their quality using the AGREE tool and to examine the evidence cited in support of their recommendations. METHODOLOGY: The primary sources to identify published guidelines were MEDLINE (Ovid® ) and EMBASE. The search aim was to identify guidelines pertaining to the post-root canal treatment follow-up recommendations published from 1946 with the final search date being 26 June 2016. The primary search was supplemented by searching Internet search engines and several websites that might have guidelines. The guidelines obtained from the search end-result were assessed for quality and scientific evidence using the AGREE II instrument. Similarities and differences in the recommendations were identified. RESULTS: Thirty guidelines were identified, seven of which met the inclusion criteria. Two guidelines used and clearly described the methods for obtaining scientific evidence from which the recommendations were set. The recommendations varied, particularly as regards the timing of the first review radiograph. Some guidelines lacked supporting evidence. CONCLUSIONS: The recommendations for post-root canal treatment radiographic follow-up varied amongst the identified guidelines. However, the methodology for obtaining the scientific evidence was poorly described in most of the guidelines. Guideline development groups should use the AGREE II instrument as a guide to produce higher quality guidelines.

Detecting the earliest radiological signs of bisphosphonate-related osteonecrosis.

Introduction Oral bisphosphonates are the most commonly prescribed anti-resorptive drugs used in the treatment of osteoporosis, but osteonecrosis of the jaw is a serious complication. The early diagnosis of this destructive side effect is crucial in preventing excessive bone loss, pain and infection.Objective To aid dental practitioners in the early identification of bisphosphonate-related osteonecrosis of the jaw.Method A scoping review was carried out.Data sources We searched MEDLINE via OVID, EMBASE via OVID, Dentistry and Oral Sciences Source (DOSS), Proquest Dissertation and Theses Search, to identify references that described clinical and radiological findings in medication-related osteonecrosis of the jaw (MRONJ).Data selection Nineteen references mentioned the earliest radiological changes in MRONJ with a description of the observations and were included in the analysis.Data synthesis The radiographic signs included osteosclerosis/lysis, widening of the periodontal ligament and thickening of the lamina dura and cortex. To assess the quality of original data on which recommendations had been made, these 19 studies were subjected to a quality appraisal.Conclusion Using bone exposure as a criterion for diagnosis of MRONJ, leads to delayed diagnosis and a poor response to treatment. In those patients at risk of bone exposure with MRONJ, insufficient information is present in the literature to allow the general dental practitioner to reliably identify the radiographic features indicating imminent bone exposure. A well-designed prospective study is needed.

Guidelines on the timing and frequency of bitewing radiography: a systematic review.

Objectives To identify guidelines on when and how frequently bitewing radiographs should be used in dentistry for the diagnosis of caries, and to provide an objective appraisal of their quality.Data sources MEDLINE (OVID), US National Guideline Clearinghouse (www.guideline.gov) and the Royal College of Surgeons of England (https://www.rcseng.ac.uk/fds/publications-clinical-guidelines/clinical_guidelines) websites were searched using a variety of relevant search terms (2 August 2016).Data selection Publications were included if they made recommendations on the issue of when and how frequently radiographs should be used in any dentally-related specialty pertaining to the diagnosis of caries; and/or if they were aimed at the individual practitioner (any health professional working within dentistry) and/or patients.Data analysis Thirteen published guidelines were included and assessed using the AGREE II instrument.Conclusions There was a significant variation amongst the guidelines in the recommendations at what age radiography should be undertaken. There was also disagreement on the frequency of repeat radiographs and how this is influenced by the age of the patient and their caries risk.

Challenges in X-ray diagnosis: a review of referrals for specialist opinion.

The aim of this study was to determine the common reasons why a dental professional might request a second opinion on a dental radiograph from a Dental and Maxillofacial (DMF) radiologist. The study was a retrospective analysis of consecutive referrals for an opinion received by post or email by one DMF radiologist based in a UK dental hospital. The study period was from March 2009 to November 2015. Referrals came from a mixture of sources: mainly from general dental practitioners and specialists working in primary care, but with some referrals from hospital-based practitioners. An enormous range in diagnoses were made by the DMF radiologist, but the ten most frequent diagnostic categories contributed 57.5% of the total. Normal anatomy and anatomical variations in normal anatomy made up the largest category. Common dental disease was often diagnosed, but idiopathic osteosclerosis and maxillary antrum pathosis were both frequent reasons for seeking a second opinion. This service evaluation may assist in developing curricula for undergraduates and in designing continuing education courses. It also highlights a service that may avoid unnecessary referrals to hospital specialists but which currently is not commissioned by the NHS.

Impact of cone beam computed tomography (CBCT) on diagnostic thinking in endodontics of posterior teeth: A before- after study.

OBJECTIVES: The aim of this study was to evaluate the impact of limited volume CBCT upon diagnosis as part of endodontic management of posterior teeth. The null hypothesis that CBCT does not make any difference in endodontic diagnosis was tested. METHODS: A single-centre "before-after" study was conducted in a secondary healthcare establishment. Eligible patients were all adults aged 18 years or over who were referred to a specialist endodontic unit. Further inclusion criteria were that the cases were either re-treatment or de novo root canal treatment where the anatomy was judged to be complex. Exclusion criteria included vulnerable groups and de novo endodontic treatment with uncomplicated root canal anatomy. As well as a full history and clinical examination, a high quality colour photographic intraoral image, two paralleling technique periapical radiographs and limited volume CBCT examination were carried out for each patient. All components, except the CBCT dataset, were combined into a Powerpoint presentation and assessed by 4 observers. A questionnaire was designed for the observers as part of the study. RESULTS: CBCT information only changed the radiological findings and the final diagnosis in a minority of cases. There was no clear evidence that CBCT increases the confidence of observers or that CBCT was helpful in making a diagnosis. CONCLUSIONS: Routine use of CBCT cannot not be justified on the basis of a change in diagnosis and carefully selected use is appropriate. CLINICAL SIGNIFICANCE: CBCT is being increasingly used in the field of endodontics. The benefits gained from the use of CBCT must be carefully balanced against the increased radiation dosage. Determination of selection criteria for the use of CBCT in endodontics is, therefore, essential.

Justification and good practice in using handheld portable dental X-ray equipment: a position paper prepared by the European Academy of DentoMaxilloFacial Radiology (EADMFR).

Handheld portable X-ray devices are increasingly used for intraoral radiography. This development introduces new challenges to staff and patient safety, for which new or revised risk assessments must be made and acted upon prior to use. Major issues might be: difficulties in using rectangular collimation with beam aiming devices, more complex matching of exposure settings to the X-ray receptor used (e.g. longer exposure times), movements owing to the units' weight, protection of the operator and third persons, and the use in uncontrolled environments. These problems may result in violation of the "as low as reasonably achievable'', that is, ALARA principle by an increase in (re)exposures compared with the other available intraoral X-ray devices. Hence, the use of handheld portable X-ray devices should be considered only after careful and documented evaluation (which might be performed based on medical physics support), when there is evidence that handheld operation has benefits over traditional modalities and when no new risks to the operators and/or third parties are caused. It is expected that the use of handheld portable X-ray devices will be very exceptional, and for justified situations only. Special attention should be drawn to beam-aiming devices, rectangular collimation, the section of the X-ray receptor, focus-skin distance, and backscatter shielding, and that the unit delivers reproducible dose over the full set of environmental conditions (e.g. battery status and temperature).

The impact of premature birth on the mandibular cortical bone of children.

SUMMARY: Children born prematurely often have reduced skeletal mineralization. The aim in this study was to compare the cortical thickness of the lower jaw on radiographs of 8- to 10-year-old children with histories of preterm or full term births. There were no significant differences in cortical thickness between full term and preterm children at this age. INTRODUCTION: The purpose of this study was to compare the cortical thickness of the mandible on panoramic radiographs of 8- to 10-year-old children with histories of preterm or full term births. METHODS: Panoramic radiography was performed on 36 extremely preterm, 38 very preterm and 42 full term children at the age of 8 to 10 years. Five observers independently measured the mandibular cortical width on the panoramic radiographs at four defined sites bilaterally. Altogether, 928 sites were available. Measurements were performed twice on a random 24% of the sites by four observers. One-way analysis of variance with Tukey's post hoc test was used to test differences between groups. Intraclass correlation coefficient (ICC) was calculated for interobserver agreement while intra-observer agreement was expressed as measurement precision. RESULTS: Significant differences of mandibular cortical width were found between extremely preterm and very preterm children for five of the eight measurement sites with the very preterm showing the highest value. No significant differences were found between full term and either very preterm or extremely preterm except for one measurement site, with the extremely preterm showing the lowest value. ICC varied between 0.30 and 0.83 for the different sites (mean 0.62). The precision of a single measurement varied between 0.11 and 0.45 mm (mean 0.25 mm). CONCLUSIONS: From the evidence that very preterm children had significantly thicker mandibular cortices than extremely preterm children, we suggest that these findings may reflect the effect of mineral supplementation provided to premature infants, causing a 'shifting up' of bone mineral status relative to the full term peer group while maintaining the difference between very preterm and extremely preterm born children.

Guidelines for clinical use of CBCT: a review.

OBJECTIVES: To identify guidelines on the clinical use of CBCT in dental and maxillofacial radiology, in particular selection criteria, to consider how they were produced, to appraise their quality objectively and to compare their recommendations. METHODS: A literature search using MEDLINE (Ovid(®)) was undertaken prospectively from 1 January 2000 to identify published material classifiable as "guidelines" pertaining to the use of CBCT in dentistry. This was supplemented by searches on websites, an internet search engine, hand searching of theses and by information from personal contacts. Quality assessment of publications was performed using the AGREE II instrument. Publications were examined for areas of agreement and disagreement. RESULTS: 26 publications were identified, 11 of which were specifically written to give guidelines on the clinical use of CBCT and contained sections on selection criteria. The remainder were a heterogeneous mixture of publications that included guidelines relating to CBCT. Two had used a formal evidence-based approach for guideline development and two used consensus methods. The quality of publications was frequently low as assessed using AGREE II, with many lacking evidence of adequate methodology. There was broad agreement between publications on clinical use, apart from treatment planning, in implant dentistry. CONCLUSIONS: Reporting of guideline development is often poorly presented. Guideline development panels should aim to perform and report their work using the AGREE II instrument as a template to raise standards and avoid the risk of suspicions of bias.

Effectiveness of thyroid gland shielding in dental CBCT using a paediatric anthropomorphic phantom.

OBJECTIVES: The purpose of the study is to evaluate the effectiveness of thyroid shielding in dental CBCT examinations using a paediatric anthropomorphic phantom. METHODS: An ATOM(®) 706-C anthropomorphic phantom (Computerized Imaging Reference Systems Inc., Norfolk, VA) representing a 10-year-old child was loaded with six thermoluminescent dosemeters positioned at the level of the thyroid gland. Absorbed doses to the thyroid were measured for five commercially available thyroid shields using a large field of view (FOV). RESULTS: A statistically significant thyroid gland dose reduction was found using thyroid shielding for paediatric CBCT examinations for a large FOV. In addition, a statistically significant difference in thyroid gland doses was found depending on the position of the thyroid gland. There was little difference in the effectiveness of thyroid shielding when using a lead vs a lead-equivalent thyroid shield. Similar dose reduction was found using 0.25- and 0.50-mm lead-equivalent thyroid shields. CONCLUSIONS: Thyroid shields are to be recommended when undertaking large FOV CBCT examinations on young patients.

The impact of CBCT imaging when placing dental implants in the anterior edentulous mandible: a before-after study.

OBJECTIVES: To evaluate the impact of CBCT imaging when placing dental implants in the anterior edentulous mandible, using a "before-after" study design. METHODS: Eight dental practitioners, who regularly place dental implants in independent dental practice in the North West of England, were presented with realistic simulations of four edentulous cases. The practitioners were asked to assess case difficulty, select implants and then drill osteotomies in preparation for dental implants in the lower canine regions to support a complete overdenture. In the "before" part of the study, a panoramic and a trans-symphyseal view were available. In the "after" part of the study, a CBCT image was added. Perception of case difficulty, implant selection and the incidence of perforations or "near miss perforations" of the lingual cortical plate were recorded. Two cases were regarded as "regular" and two as "challenging". RESULTS: In challenging cases, the availability of CBCT led practitioners to select narrower implants and to assess cases as more difficult. In the challenging cases only, there were fewer perforations of the lingual cortical plate after the availability of CBCT, but this difference was not statistically significant. There were no perforations in the regular cases either before or after the availability of CBCT. CONCLUSIONS: Perception of case difficulty and implant selection are of importance only if they change the outcome for the patient. This study provided weak evidence that CBCT is helpful in avoiding perforations in challenging cases. The availability of CBCT had no impact in regular cases.