Diagnostic accuracy studies needed for cone beam computed tomography.

DATA SOURCES: Medline, Embase, CENTRAL and the reference lists of identified studies. STUDY SELECTION: Studies had to describe diagnostic accuracy efficacy, diagnostic thinking efficacy, therapeutic efficacy or any combination for CBCT in the diagnosis of impacted teeth or of important features associated with impactions. Criteria for the diagnosis had to be described in detail or referenced. For studies elucidating only observer performance, the analysis had to be based on a minimum of two observers. DATA EXTRACTION AND SYNTHESIS: Data were extracted with the aid of protocol based on critical appraisal of diagnostic studies. Two authors independently assessed the quality and internal validity of studies using the QUADAS tool,(1) with disagreements being resolved by discussion. The results were described narratively as meta-analyses could not be conducted. RESULTS: The search yielded 96 titles, of which seven were included. There was only limited evidence for diagnostic efficacy expressed as sensitivity, specificity and predictive values. Only two studies compared CBCT and panoramic radiographs with a valid reference method and presented the results in terms of percentage of correct diagnoses. CONCLUSIONS: There is a need for diagnostic accuracy studies on CBCT where accepted methodological criteria for diagnostic thinking, efficacy and therapeutic efficacy are incorporated.

Estimation of x-ray radiation related cancers in US dental offices: Is it worth the risk?

OBJECTIVES: The objective of this study was to estimate the possible number of cancer cases produced during 2019 in US dental offices from radiography, estimate the possible reduction in those rates resulting from use of intraoral rectangular collimation and selection criteria, and determine the frequency and quality of website radiation risk information and informed consent forms. STUDY DESIGN: An analysis of dental radiation examinations in 2014 to 2015 US national survey data, Nationwide Evaluation of X-ray Trends, and National Council on Radiation Protection and Measurements surveys was performed, in addition to an analysis of 2008 to 2020 Journal of Clinical Orthodontics national orthodontic surveys for radiographic examination frequencies. Lifetime attributable cancer risk estimates from US and European studies were used to generate the total dental and orthodontic office cancer totals. In total, 150 offices were examined online for the quality and frequency of risk information in websites and consent forms. RESULTS: The 2019 estimate for all office cancers is 967. Collimation and selection criteria could reduce this to 237 cancer cases. Most cancers arise from intraoral and cone beam computed tomography examinations, with 135 orthodontic cancers over 21 months (average treatment time). Collimation and selection criteria could reduce this to 68. Only 1% of offices use collimators or informed consent for radiography. The website and consent information were of poor quality. CONCLUSIONS: Dentists are not following selection criteria or using collimators according to guidelines. Up to 75% of cancer cases could be avoided.

A radiographic method for distinguishing noncavitated from cavitated proximal carious lesions: A proof of concept clinical trial.

OBJECTIVES: We propose a new topical radiographic contrast method for distinguishing noncavitated from cavitated radiolucencies. Laboratory tests and a pilot clinical trial were designed to test the feasibility and efficacy of the method. STUDY DESIGN: Twenty-two adults with 27 proximal radiolucencies had conventional bitewing (BW) examinations. After exclusion, 21 surfaces were evaluated. A concentrated solution of sodium iodide was placed in the interdental spaces via a microsyringe and BWs were again exposed. A class II cavity preparation was made in the adjacent tooth and polysiloxane impressions were made of the study surfaces. The impressions were scanned by visible light, creating a high resolution 3D replica. Cavitations, if present, were measured. RESULTS: Nine surfaces were noncavitated and 12 surfaces were cavitated. The microsyringe dispensed a variable volume of liquid, which affected the accuracy of the test. The sensitivity for cavitation was 50%, specificity was 88.9%, and accuracy was 66.7%. This compares to a reported 60% sensitivity, 62% specificity, and 62% accuracy for BW examinations. Intraexaminer reliability for classifying noncavitated or cavitated lesions using the kappa test was 0.649. CONCLUSIONS: This method needs improvement but was an advance over conventional BWs and could result in reduction of restorations in low- and high-risk patients.

Digital Radiographic Image Processing and Analysis.

This article describes digital radiographic imaging and analysis from the basics of image capture to examples of some of the most advanced digital technologies currently available. The principles underlying the imaging technologies are described to provide a better understanding of their strengths and limitations.

Accuracy of computer-assisted radiographic measurement of interproximal bone loss in vertical bone defects.

Objective. The objective of the present study was to compare 2 different computer-assisted analysis systems with respect to the measurement of interproximal bone loss on radiographs. Study Design. In 14 patients with untreated advanced periodontal disease, 90 standardized radiographs were taken presurgically and during postoperative follow-up. During periodontal surgery for 30 vertical bone defects and 28 adjacent sites (22 vertical, 3 horizontal, and 3 without bone loss), the distances from the cementoenamel junction (CEJ) to the alveolar crest (AC) and from the CEJ to the bottom of bony defect (BD) were measured. In all radiographs, the linear distances from the CEJ to the AC and from the CEJ to BD were assessed by using 2 computer-assisted analysis devices: linear measurement (LMSRT) and FRIACOM (FRIADENT, Mannheim, Germany). A comparison between the radiographic and intrasurgical assessments was performed by using the paired t test. Results. With respect to the linear distance from the CEJ to the BD, the study failed to detect statistically significant differences between the computer-assisted techniques and intrasurgical measurement as the gold standard (LMSRT,: 0.26 +/- 2.16 mm [P >.05]; FRIACOM, 0.35 +/- 2.5 mm [P >.05]). In terms of the distance from the CEJ to the BD and from the CEJ to the AC, the correlation between both computer-assisted methods was excellent (r(s) > or = 0.75) and there were no statistically significant differences detectable between LMSRT and FRIACOM for both distances. With regard to the distance from the CEJ to the AC, both techniques overestimated interproximal bone loss as compared with intrasurgical measurements (CEJ-AC, LMSRT: 1.63 +/- 2.52 mm [P <.01]; FRIACOM: 2.00 +/- 2.48 mm [P <.01]). The amount of overestimation of interproximal bone loss did not differ significantly in either computer-assisted technique (P >.05). For double measurements, both LMSRT and FRIACOM showed excellent reproducibility with coefficients of variation that ranged between 3.8% and 4.5% (CEJ-BD) and between 5.7% and 6.6% (CEJ-AC). There were no statistically significant differences between the reproducibilities of both computer-assisted techniques (P <.05). Conclusions. Both LMSRT and FRIACOM are reproducible methods to measure the distances from the CEJ to the BD and from the CEJ to the AC on radiographs and can be recommended for clinical use. With respect to the distance from the CEJ to the AC, it must be kept in mind that both computer-assisted methods tend to overestimate the real distance on an average of 1.5 to 2.0 mm.

Applying evidence-based dentistry to caries management in dental practice: a computerized approach.

BACKGROUND: It has been suggested that dentists manage patients' treatment according to their risk of developing caries, as determined on the basis of scientific findings-an example of applying evidence-based dentistry, or EBD, to caries management. This article evaluates the barriers to adopting EBD and suggests possible outcomes for dentists and patients if new EBD caries strategies are adopted. METHODS: The author estimated the complexity of adopting EBD for a general dentist by means of flowchart analysis. He considered the ease of collecting comprehensive patient screening data, identifying risk factors and classifying risk. He examined the adequacy of conventional caries charting methods for representing the different stages and behavior of carious lesions, as well as the difficulty of producing treatment plans according to different caries risk levels. He also modeled the possible financial and organizational results of applying EBD caries management methods and increasing the use of hygienists. RESULTS: Traditional caries management strategies required only one flowchart page, while EBD needed 16 pages. Two full-time hygienists and 25 percent of a dentist's time, managing only patients at low risk of developing caries, could generate the equivalent gross income of a full-time dentist working conventionally. Adding a third hygienist and devoting 75 percent of a dentist's time to managing the remaining patients (those at medium or high risk of developing caries and periodontal disease) could gross a similar amount again. CONCLUSIONS: Changing from traditional to risk-based management of caries requires complex decision making that is unlikely to occur with paper chart methods. Computers are ideal for collecting patient screening data and automating the treatment planning process to reduce the complexity of clinical management. Conventional methods of charting caries are not suited for evidence-based caries risk management. PRACTICE IMPLICATIONS: One dentist who uses risk-based management of caries and makes efficient use of three hygienists may see a doubling of income and a fourfold increase in the practice's patient population.

Professional monopoly, social covenant, and access to oral health care in the United States.

Lack of access to oral care is a severe problem in the United States with over one-third of the population lacking dental insurance. In this group, 32 million people lack dental insurance and access to public dental services (Medicaid or Medicare), and 7 million of them need dental care. In some high-risk populations, such as Native Americans, two-thirds have unmet dental needs. Only 1 percent of Medicaid-eligible babies have a dental examination before twelve months of age. In this paper the social covenant of the dental profession is examined and suggestions made for improving access to care through improved efficiency. It is proposed that 1) private dentists should accept 5 percent per annum of their patients for indigent care funded by improved efficiency from utilizing allied dental providers (ADP) in new roles, and 2) ADP should have their own independent state boards. If dentists refuse to honor their social covenant, then ADP should be allowed to practice independently, breaking the professional monopoly.