The impact of Cone Beam CT on financial costs and orthodontists' treatment decisions in the management of maxillary canines with eruption disturbance.

Background: Examination with Cone Beam CT (CBCT) is common for localizing maxillary canines with eruption disturbance. The benefits and costs of these examinations are unclear. Objectives: To measure: 1. the proportion of orthodontists' treatment decisions that were different based on intraoral and panoramic radiography (M1) compared with CBCT and panoramic radiography (M2); and 2. the costs of producing different treatment plans, regarding patients with maxillary canines with eruption disturbance. Subjects and methods: Orthodontists participated in a web-based survey and were randomly assigned to denote treatment decisions and the level of confidence in this decision for four patient cases presented with M1 or M2 at two occasions for the same patient case. Results: One hundred and twelve orthodontists made 445 assessments based on M1 and M2, respectively. Twenty-four per cent of the treatment decisions were different depending on which method the raters had access to, whereof one case differed significantly from all other cases. The mean total cost per examination was €99.84 using M1 and €134.37 using M2, resulting in an incremental cost per examination of €34.53 for M2. Limitations: Benefits in terms of number of different treatment decisions must be considered as an intermediate outcome for the effectiveness of a diagnostic method and should be interpreted with caution. Conclusions: For the patient cases presented in this study, most treatment decisions were the same irrespective of radiological method. Accordingly, this study does not support routine use of CBCT regarding patients with maxillary canine with eruption disturbance.

Automatic Synthesis of Panoramic Radiographs from Dental Cone Beam Computed Tomography Data.

In this paper, we propose an automatic method of synthesizing panoramic radiographs from dental cone beam computed tomography (CBCT) data for directly observing the whole dentition without the superimposition of other structures. This method consists of three major steps. First, the dental arch curve is generated from the maximum intensity projection (MIP) of 3D CBCT data. Then, based on this curve, the long axial curves of the upper and lower teeth are extracted to create a 3D panoramic curved surface describing the whole dentition. Finally, the panoramic radiograph is synthesized by developing this 3D surface. Both open-bite shaped and closed-bite shaped dental CBCT datasets were applied in this study, and the resulting images were analyzed to evaluate the effectiveness of this method. With the proposed method, a single-slice panoramic radiograph can clearly and completely show the whole dentition without the blur and superimposition of other dental structures. Moreover, thickened panoramic radiographs can also be synthesized with increased slice thickness to show more features, such as the mandibular nerve canal. One feature of the proposed method is that it is automatically performed without human intervention. Another feature of the proposed method is that it requires thinner panoramic radiographs to show the whole dentition than those produced by other existing methods, which contributes to the clarity of the anatomical structures, including the enamel, dentine and pulp. In addition, this method can rapidly process common dental CBCT data. The speed and image quality of this method make it an attractive option for observing the whole dentition in a clinical setting.

Cost-based decision analysis of postreduction imaging in the management of mandibular fractures.

IMPORTANCE: Immediate postreduction imaging is a standard practice in the management of mandibular fractures at many hospitals. However, the literature suggests that postreduction imaging in maxillofacial fractures fails to influence clinical decision making significantly. OBJECTIVES: To determine the cost-effectiveness of different clinical decision pathways regarding postreduction imaging as it relates to the experience of the surgeon, and to demonstrate that baseline postreduction imaging has utility based on the complication rate of the surgeon. DESIGN, SETTING, AND PARTICIPANTS: We developed a decision tree model using commercially available software. The model accounted for cost of imaging modalities, adequacy of reduction, complication rate, cost of initial operating room time, and, if applicable, operative charges for revision surgery in the event of a complication. A review of the University of Virginia clinical data repository of 100 patients with recent mandible fractures was used to estimate the cost associated with running an operating suite for mandibular fracture repair. The University of Virginia billing system also provided costs associated with a single computed tomogram, panoramic radiography, and intraoperative 3-dimensional computed tomography. A sensitivity analysis determined how variation in complication rate affects the cost of the decision pathways. INTERVENTION: Intraoperative imaging, postreduction imaging, or no imaging. MAIN OUTCOMES AND MEASURES: Sensitivity of the decision tree model to variation in complication rate. RESULTS: Using current hospital charges, the model is sensitive to variability in the complication rate with a breakpoint of 17.7%. It is most cost-effective to obtain a post-reduction panorex if the surgeon's complication rate is above 17.7% and most cost-effective not to obtain any postreduction imaging if the complication rate is below 17.7%. Intraoperative computed tomography is not cost-effective at any complication rate. Two-way sensitivity analysis allowed the model to be generalizable to varied institutional costs and surgical complication rates. CONCLUSIONS AND RELEVANCE: The utility of postreduction imaging from the standpoint of cost analysis depends on the complication rate of the facial traumatologist and institutional charge data. Based on this model, the facial traumatologist at our institution should obtain postreduction panorex imaging for patients with mandible fractures until their complication rate drops below 17.7%. The 2-way sensitivity analysis in this study allows the facial traumatologist to apply his or her complication rate and institutional cost data to determine whether routine postreduction imaging is necessary. LEVEL OF EVIDENCE: NA.

Early detection of osteoporosis from incisure depth of human mandible in an orthopantomogram.

OBJECTIVES: To see the correlation between changes in incisure depth of mandible on an orthopantomogram with bone mineral density and whether or not it can be employed for screening and early detection of osteoporosis. METHOD: The analytical cross-sectional study was conducted at the Institute of Basic Medical Sciences, Dow University of Health Sciences, Karachi, from December 2011 to July 2012. It comprised 174 female subjects between 25 and 85 years of age who were divided into premenopausal (Group I) and postmenopausal (Group II) groups. Group I and Group II were further subdivided into normal (pre A, post A), osteopenic (pre B, post B) and osteoporotic (pre C, post C) groups on the basis of Dual EnergyX-ray Absorptiometry scan. Changes in mandibular incisure depth seen on orthopantomogram in subgroups of Group I were compared with each other and with subgroups of Group II. SPSS 16 was used for statistical analysis. One-way Analysis Of Variance was applied to evaluate intra-group significance. For inter-group significance, independent samples t-test was applied. RESULTS: The depth of mandibular incisure was found to be significantly increased in osteoporotic patients (p < 0.05). CONCLUSION: The simple screening tool can be employed for early detection of osteoporosis in a cost-effective manner.

Image and surgery-related costs comparing cone beam CT and panoramic imaging before removal of impacted mandibular third molars.

OBJECTIVES: The aim of this prospective clinical study was to derive the absolute and relative costs of cone beam CT (CBCT) and panoramic imaging before removal of an impacted mandibular third molar. Furthermore, the study aimed to analyse the influence of different cost-setting scenarios on the outcome of the absolute and relative costs and the incremental costs related to surgery. METHODS: A randomized clinical trial compared complications following surgical removal of a mandibular third molar, where the pre-operative diagnostic method had been panoramic imaging or CBCT. The resources implied in the two methods were measured with health economic tools. The primary outcome was total costs defined as the sum of absolute imaging costs and incremental surgery-related costs. The basic variables were capital costs, operational costs, radiological costs, radiographic costs, overheads and patient resource utilization. Differences in resources used for surgical and post-surgical management were calculated for each patient. RESULTS: Converted to monetary units, the total costs for panoramic imaging equalized €49.29 and for CBCT examination €184.44. Modifying effects on this outcome such as differences in surgery time, treatment time for complications, pre- and post-surgical medication, sickness absence, specialist treatment and hospitalization were not statistically significant between the two diagnostic method groups. CONCLUSIONS: Costs for a CBCT examination were approximately four times the costs for panoramic imaging when used prior to removal of a mandibular third molar. The use of CBCT did not change the resources used for surgery, post-surgical treatment and patient complication management.

What costs are associated with the management of third molars?

PURPOSE: The purpose of this study was to estimate the treatment costs directly related to operative and nonoperative management of asymptomatic, disease-free, third molar (M3) teeth. MATERIALS AND METHODS: The data reviewed were limited to claims submitted by oral and maxillofacial surgeons. The data collected included charges for consultations, radiographs, surgical removal of bony impacted teeth, and general anesthesia, using the 2009 data extracts from Delta Dental of Virginia. The median charges were used as a proxy for the actual costs attributable to the removal or retention of M3 teeth. Three clinical scenarios were executed using the available claims data to calculate the treatment costs associated with nonoperative and operative M3 management. An assumption made in the computation of expenses was that for subjects who elected to retain their M3s, the recommended management strategy was active surveillance. Active surveillance is a prescribed treatment to monitor the retained M3s characterized by performing a clinical examination and panoramic imaging every 2 years. The author assumed a 3% increase in charges per annum. RESULTS: The 3 scenarios were as follows: scenario 1 (nonoperative management), retention of asymptomatic, disease-free M3s and monitoring for 20 years from age 18 to 38 years; scenario 2 (operative management), removal of 2 asymptomatic, disease-free, bony impacted M3s for 18-year-old patients using general anesthesia (30 minutes) in an office-based ambulatory setting; and scenario 3 (failure of non-operative management), removal of 1 previously asymptomatic, disease-free, bony impacted M3 after 10 years of follow-up in a now 28-year-old patient using general anesthesia (30 minutes) in an office-based ambulatory setting. The estimated charges for managing M3s were $2,342, $1,184, and $1,997 for scenarios 1, 2, and 3, respectively. CONCLUSIONS: A simplified financial analysis derived from the dental claims data suggests that during the course of the patient's lifetime, the charges associated with non-operative management of asymptomatic, disease-free M3s will exceed the charges of operative management. The difference in costs might be important to patients when choosing between operative and non-operative management of their M3s.

The role of the dental surgeon in detecting osteoporosis: the OSTEODENT study.

OBJECTIVE: To determine if thinning (<3 mm width) of the lower cortical border of the mandible on dental panoramic radiographs, as well as other clinical risk factors, may provide a useful diagnostic test for osteoporosis in young postmenopausal women. DESIGN: Six hundred and fifty-two subjects (age range 45-70 years) were involved in this multi-centre, cross-sectional study. SETTING: Patients were recruited from centres in Leuven (Belgium), Athens (Greece), Manchester (UK), and Malmo (Sweden). SUBJECTS AND METHODS: The subject's age, body weight, whether the patient took hormone replacement therapy or had a history of low trauma fracture were used to form a clinical osteoporosis risk assessment (the OSteoporosis Index of RISk or OSIRIS index). Each patient also received a dental panoramic radiographic examination. RESULTS: One hundred and forty subjects had osteoporosis involving at least one of the measurement sites (lumbar spine, femoral neck or total hip). Those with osteoporosis tended to have a low OSIRIS score and a thinned cortical mandibular border. The area under the ROC curve for using both cortical width and OSIRIS to predict osteoporosis was 0.90 (95% CI = 0.87 to 0.92). There was a significant improvement in the diagnostic ability of the combined OSIRIS and cortical width test over both tests applied separately (p <0.001). The cost effectiveness of the cortical width and OSIRIS model was improved by using a high specificity threshold rather than high sensitivity. However, this analysis ignores the costs associated with missed cases of osteoporosis. CONCLUSION: Dentists have a role to play in the detection and referral of patients at high risk of osteoporosis.

Correlating carotid artery stenosis detected by panoramic radiography with clinically relevant carotid artery stenosis determined by duplex ultrasound.

OBJECTIVE: We sought to assess the utility of panoramic radiography as an adjunct screening tool for detecting significant asymptomatic carotid artery stenosis. The specific aim was to correlate calcifications seen in the region of the carotid bifurcation with clinically relevant carotid artery stenosis as determined by duplex ultrasound (DUS). STUDY DESIGN: Routine dental panoramic films of patients 55 and older (n = 778) at the University of Rochester Eastman Dental Center were retrospectively reviewed for calcifications around the carotid bifurcation. Patients with such calcifications were referred for DUS, and raw data were interpreted by a vascular surgeon blinded to the radiographic findings. Groups were compared by using the chi(2) test. RESULTS: Twenty-seven patients (3.5%) had suggestive radiographic calcifications on one or both sides, 20 of whom consented to DUS. Clinically significant carotid stenoses (>50% lumenal narrowing) were present in 50% of the sides with calcification compared with 21% of the sides without (P =.08, chi(2)). Three patients (15% of those screened with DUS) had stenoses greater than 80% and underwent 4 carotid endarterectomies as a direct result of screening. CONCLUSIONS: Data suggest that clinically significant stenosis may exist if calcifications are observed on panoramic radiographs. Incidental examination of this area carries a minimal cost and appears beneficial as a screening tool for carotid disease, although definitive testing must follow.

Extraoral and panoramic systems.

Digital solutions for extraoral and panoramic radiology have been available for more than 15 years. The costs, however, have been too high for adoption in private dental practice. The past 2 years have seen tremendous growth in the number of relatively cost-effective digital options available to the dentist and dental specialist. Furthermore, computer speed and data storage capacities have progressed. This article presents an overview of systems available at present, and their enabling technologies and enhancement capabilities.

[Value of dental CT for the implant specialty in mouth, jaw and facial surgery]. / Die Bedeutung des Dental-CT für die Implantologie in der Mund-, Kiefer- und Gesichtschirurgie.

The importance of dental CT in comparison to conventional OPT in implantation diagnostics is demonstrated in specific indication groups (atrophy of upper and lower jaw, patient after tumor and reconstructive surgery). The application of radiological techniques is illustrated in relation to diagnostic information quality, radiation exposure and cost effectiveness regarding clinical routine use.

Panoramic radiography in dental diagnostics.

Panoramic radiography was studied with the aim to answer some questions about technical and diagnostic properties regarding dental diagnostics. A unit with an intraoral X-ray tube was studied regarding radiation beam area, absorbed doses, and image quality for various screen-film combinations. The beam area for lateral views was wider than optimal and the contact dose high. Modifications of shielding cylinders would reduce both radiation beam and contact dose. One screen-film combination was most sensitive and produced radiographs with best subjectively perceived image quality. Agreement between panoramic (rotational and intraoral X-ray tube techniques) and intraoral radiography in diagnosis of periapical pathology, assessment of marginal bone height, and caries diagnosis was evaluated in 400 patients. Average agreement between panoramic and intraoral radiographs in periapical diagnosis was 55% for the rotational and 46% for the intraoral tube technique. Agreement in marginal bone height was 55% and 49%, respectively and in caries diagnosis 34% and 46%. Radiographs from 40 patients were used to evaluate a procedure starting with rotational panoramic radiography followed by intraoral radiographs considered necessary to achieve a comprehensive examination of teeth and surrounding bone. The number of intraoral radiographs, information loss, and monetary costs with this procedure were evaluated. Mean number of adjunct intraoral radiographs was 5.1 per patient whilst 8.5 should have been chosen to satisfy a "gold standard" used. Monetary costs were similar for an optimal combination of panoramic and intraoral radiography as for a survey with 20 intraoral images Sensitivity for a combination of radiographs was 80-96% in periapical diagnosis and marginal bone loss assessment, and 42-96% in caries diagnosis. Specificity was 95-97% for periapical and caries diagnosis and 50-92% for marginal bone loss. Radiographs from six conventional units and two programs ("dental" and "jaw" panorama) of a new multi-modal unit were compared in diagnostic quality of periapical and crestal bone areas. Number of adjunct intraoral radiographs to achieve a comprehensive evaluation of periapical and marginal bone was estimated. Quality of the "dental" panorama was significantly better than that of other machines/programs. There were no significant differences between images obtained with conventional units and the "jaw" panorama. Number of adjunct intraoral radiographs was lowest for the "dental" panorama. Quality obtained with an old unit was similar to that from modern machines. Rotational and intraoral X-ray tube panoramic radiography perform equally well. Agreement between panoramic and intraoral radiography is not sufficient for panoramic radiography to be used alone to diagnose periapical lesions, marginal bone loss and caries. It is possible to perform a full-mouth survey with a combination of panoramic and intraoral radiography but when limited regions need to be examined intraoral radiography is the method of choice.

Panoramic and restrictive intraoral radiography in comprehensive oral radiographic diagnosis.

It has been suggested that information from the panoramic radiograph makes it possible to appropriately select supplementary intraoral radiographs to achieve a comprehensive examination of teeth and surrounding bone with less patient dose but no significant information loss. Number of intraoral radiographs selected, information loss and monetary costs with such a procedure was evaluated in 40 patients. Results show that, on average, 5.1 intraoral radiographs were selected to supplement the panoramic radiograph. Of these, 3.1 contained information different from that in the panoramic radiograph but 2.0 did not. An additional 3.4 ought to have been taken to reach the result of the 'gold standard' achieved from a simultaneous evaluation by two expert observers of panoramic radiographs and full mouth surveys with intraoral radiographs. Sensitivity for the combined use of panoramic and supplementary intraoral radiographs was high (80-96%, depending on type of teeth) as regards periapical lesions and marginal bone loss but low for caries (42-96%). Specificity was high for periapical lesions and caries (95-97%) but low for marginal bone loss (50-92%). In Sweden, patient costs become almost the same for a combination of panoramic radiography and 8.5 intraoral radiographs as for a full mouth survey comprising 20 intraoral radiographs. The radiation dose reduction is 40-50% considering that the dose from a panoramic radiograph approximately corresponds to 2-4 intraoral radiographs.(ABSTRACT TRUNCATED AT 250 WORDS)