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November 4, 2009 | dentalproductsreport.com Does your cone beam see too much? The three-dimensional cone beam scans provide new depth to diagnosis and treatment planning, but should dentists have concerns about information on non-dental conditions that can be detected in the images?  3D imaging from cone beam systems provide new levels of detail and anatomical information for treatment planning, the scans volumes contain much more information than clinicians are used to. Photo: Imaging Sciences International The amazing 3D anatomies revealed via cone beam have certainly opened plenty of eyes and aided treatment planning for implant, ortho, endo and other cases. But they could also force some practitioners to open their wallets if they fail to identify a malignancy or other serious health issue revealed in a scan. With any new medical technology it can take years before the case law is worked out and precedents are set in terms of liability, and the issue remains unsettled with cone beam. However, American Academy of Oral and Maxillofacial Radiology (AAOMR) President Allan G. Farman, BDS, PhD, said there are already some cases underway related to missed information contained in a cone beam scan, and the crux of the issue is not exactly new territory for the legal system. “Just because we have cone beam CT doesn’t mean to say that we didn’t have this issue before. People were sued before for missing lesions on panoramic radiographs and cephalometric radiographs,” he said. “It just so happens with cone beam CT we see details clearer than we could previously.” But just because cone beam scans can contain information beyond what most dentists are used to seeing and dentists could be held liable for what that information says, is not a reason to avoid the technology. Dr. Farman considers cone beam to be "a standard of care nowadays” and believes the images can be invaluable in planning many treatments to the point that not using the imaging technology could soon be considered a different type of liability. Finding the middle ground So if there are potential liabilities in scanning with cone beam and other potential liabilities in not scanning, what is a clinician to do? Case Western Reserve University Assistant Professor of Oral Diagnosis and Radiology Wisam Al-Rawi believes education is a key component to solving this dilemma. Noticing a lack of online resources for cone beam education, he created MARCILAN, a Web site providing interactive education on the technology and the basics of reading the scans for anatomy and pathology. The site provides overviews and can help dentists gain a better understanding of what they are seeing in three dimensions. Still, oral-maxillofacial radiologists (OMRs) spend several years learning to interpret the anatomical and physiological details contained in cone beam scan volumes, so while basic education can help clinicians understand what they’re looking at, calling upon an expert in the field should be standard procedure when anything questionable is detected. “It is not a trivial task that someone can just go and do straightforward,” Al-Rawi said. “My advice for those folks is that if you don’t know what it is, or you don’t have the time to read it, just send it to an oral-maxillofacial radiologist. This way you will serve the patient better.” When to scan The first step to managing liability for the data captured by cone beam scans is to use the scans appropriately in the first place. Because cone beam scans expose patients to radiation, overuse of the technology could lead to a different sort of liability, Dr. Farman said. In order to help clinicians understand what types of cases benefit most from 3D imaging, the AAOMR is working to develop a set of recommended guidelines for use of cone beam imaging. Dr. Farman said the Academy also plans to partner with the American Association of Orthodontists to create guidelines for appropriate use of cone beam imaging for orthodontic cases, where the younger age of many patients makes the issue of radiation exposure even more important. The AAOMR also is planning to implement a set of CE courses to help clinicians gain a better understanding of cone beam technology, with a focus on explaining how the technology works, and how it is best applied in different clinical situations. Dr. Farman said the goal is to help clinicians minimize radiation dose while maximizing the interpretation potential of the image volume. Other educational plans include possible credentialing for dental assistants who take cone beam images, and possible partnering with cone beam manufacturers who Dr. Farman said, “are very concerned that this type of training is provided.” Al-Rawi’s educational efforts are focused more on helping clinicians understand what they are looking at in a 3D image volume. Besides understanding the anatomies that come into play during dental procedures, he wants to continue developing his Web site to become a valuable reference for anyone looking to gain some understanding of cone beam imaging. “This is a starting point and a work in progress,” he said. “Certainly more work is needed to provide better tools and better education to the community, whether we are talking about general practitioners or dental students.” Expert opinions He hopes his Web site is helpful. But in order to become an expert at reading scan volumes, OMRs study for two years, so Al-Rawi firmly understands that no Web site can help a clinician fully understand all the details in a scan to cover any possible liability. In fact, Dr. Farman pointed out that OMRs are not experts in every part of the anatomy that can be captured by a large field cone beam scan, and even trained experts need to send scan volumes to other specialists if they are concerned by something that shows up in a scan including anatomy of the brain or neck. Working with experts at interpreting the cone beam scan data is still the best strategy to avoid liability for undetected issues captured in a scan volume because, as Al-Rawi pointed out, “The consensus is that the person who acquires the volume is responsible for it. If you take a cone beam CT scan you need to read the volume.” However, Al-Rawi said there is a good way for dentists to take advantage of the technology without acquiring the possible liabilities, or taking on the expense of purchasing a system. He recommends clinicians who only occasionally perform services that benefit from 3D imaging seek out local imaging centers that provide cone beam services. That way, the imaging center “owns” the scan volume and can have its own OMR read the data while the dentist can receive a copy of the scan data for use in treatment planning the case. Pays for itself Regardless of whether a clinician has an in-office cone beam system or is sending patients to an imaging center, the scans can pay off in a big way. The treatment planning advantages are well documented, but Dr. Farman said the relatively low cost of an OMR reading can be a solid investment as well. He works with an imaging center connected to his position on staff at the University of Louisville, and said approximately 10% of the images he receives from clinicians planning implant cases show evidence of arterial calcifications that can be precursors of stroke. In many other cases he is able to reassure clinicians who are concerned by something in a scan, that the incidental findings are not a concern. In both cases the OMR sends the report back to referring clinician, and that clinician gets to be the one to deliver the news that a patient is either in fine health or that the scan’s incidental findings caught a problem very early, so, with a referral to a medical doctor, the condition can easily be treated. “Those patients are the best advocates of that practice in the future,” Dr. Farman said. “Just simply paying the average $40-60 to have an overread for somebody who may be having tens of thousands of dollars-worth of reconstruction is certainly worth the practitioner’s time.” Noah Levine is a senior editor for DPR. Contact him at nlevine@advanstar.com.
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