CBCT in Endodontics: Advantages, Drawbacks, and Radiation Protection
Added on 2023-06-10
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Running head: DENTISTRY
Dentistry
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Author Note
Dentistry
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Name of the University
Author Note
1DENTISTRY
History of X-rays and CBCT
This section will comprise of a review of scholarly articles that encompass current
theoretical and methodological knowledge on substantive research findings, which in turn
will contribute to the topic of interest. The section will discuss published information relevant
to the two research aims, in an organized pattern by summarizing the pertinent findings. The
first aim of the research is to investigate whether the endodontists undertaking the CBCT
scans follow the justification criteria that are set out by the AAE ESE position statement.
Radiography refers to the imaging technique that depends on the use of x-rays for viewing
the internal forms of a biological object. The process of radiography encompasses creation
of a beam of electromagnetic radiation, or x-rays that are produced from a generator and
projected towards the object, currently being viewed. The discovery of x-rays is credited to
Wilhelm Röntgen, the German physicist, who was the first person to systematically conduct
a study on its functions. X-rays were found to get emanated from discharge tubes,
commonly known as Crookes tubes, which produced free electrons by residual air ionization.
Radiological cars were developed in 1914 for supporting the soldiers injured during World
War 1. A new invention, commonly known as computed tomography was developed in the
year 1972 that brought about major transformation in diagnostic medicine. No significant
changes were observed in geometry for imaging dentition since 1896. CBCT or cone beam
technology, the medical technique based on x-ray computed tomography has gained
attention in the treatment, planning and diagnosis of implant dentistry. This technique was
introduced in 1996 in Europe by QR s.r.l. (NewTom 9000) and in 2001 in the US market. The
role of CBCT in implant radiography can be attributed to the fact that the dental cone beam
has the property of offering valuable information regarding the planning and assessment of
surgical implants and is now one of the most preferred options of pre-surgical dental implant
assessments (Bornstein et al. 2014). The technique also has the capability of presenting
undistorted views of dentition that are accurately used for visualising non-erupted and
erupted teeth, and tooth roots that cannot be viewed by 2-d radiography.
History of X-rays and CBCT
This section will comprise of a review of scholarly articles that encompass current
theoretical and methodological knowledge on substantive research findings, which in turn
will contribute to the topic of interest. The section will discuss published information relevant
to the two research aims, in an organized pattern by summarizing the pertinent findings. The
first aim of the research is to investigate whether the endodontists undertaking the CBCT
scans follow the justification criteria that are set out by the AAE ESE position statement.
Radiography refers to the imaging technique that depends on the use of x-rays for viewing
the internal forms of a biological object. The process of radiography encompasses creation
of a beam of electromagnetic radiation, or x-rays that are produced from a generator and
projected towards the object, currently being viewed. The discovery of x-rays is credited to
Wilhelm Röntgen, the German physicist, who was the first person to systematically conduct
a study on its functions. X-rays were found to get emanated from discharge tubes,
commonly known as Crookes tubes, which produced free electrons by residual air ionization.
Radiological cars were developed in 1914 for supporting the soldiers injured during World
War 1. A new invention, commonly known as computed tomography was developed in the
year 1972 that brought about major transformation in diagnostic medicine. No significant
changes were observed in geometry for imaging dentition since 1896. CBCT or cone beam
technology, the medical technique based on x-ray computed tomography has gained
attention in the treatment, planning and diagnosis of implant dentistry. This technique was
introduced in 1996 in Europe by QR s.r.l. (NewTom 9000) and in 2001 in the US market. The
role of CBCT in implant radiography can be attributed to the fact that the dental cone beam
has the property of offering valuable information regarding the planning and assessment of
surgical implants and is now one of the most preferred options of pre-surgical dental implant
assessments (Bornstein et al. 2014). The technique also has the capability of presenting
undistorted views of dentition that are accurately used for visualising non-erupted and
erupted teeth, and tooth roots that cannot be viewed by 2-d radiography.
2DENTISTRY
Effects of ionizing radiation
The major deleterious effects of ionising radiations are primarily categorised into two
different types namely, stochastic and deterministic effects. The deterministic effects occur
when the exposure threshold is exceeded. Deterministic effect severity is directly
proportional to exposure dose. Some of the most common effects are cataract, sterility, skin
erythrema, and radiation sickness. However, the stochastic effects follow some linear-no-
threshold hypothesis that occurs due to ionising effects of symmetrical translocation. These
lead to cancer, and several hereditary defects such as, Down syndrome. The risk of cancer
development is found to follow some linear pattern with an increase in radiation dose (Palma
et al. 2013). The effective doses of ionising radiation are used for measuring them in terms
of their harm inflicting potential and are measured as Sievert (Sv) units. This unit also takes
into consideration the kind of radiation and organ or tissue sensitivity. The stochastic effects
of cancer appear several decades later and their likelihood is proportional to the dose of
radiation. One particular study suggested that 35.6% general private practitioners refer
CBCT. Oral radiologists (14.2%) and surgeons (21.9%) are found to be the frequent groups
who referred CBCT to the patients, followed by prosthodontists and orthodontists (Warhekar
et al. 2015). The technique is also referred for the use of conservative dentistry, oral
diagnosis, and general dentistry. Another study provided evidence for the fact that
periodontics (21%), prosthodontics (14%), and dental professionals with advance education
in dentistry (13%) were some of the most requested resident providers, with regards to use
of CBCT (Fewins 2017). The mean age of patient referrals was found to be 45 ± 21 years
with a predominance of 62% women. Most patient referrals were made from periodontolgy
specialists (17%) and maxillofacial surgeons (51%) (Arnheiter, Scarfe and Farman 2006).
Radiation protection
The use of the CBCT technique commonly spans a plethora of clinical procedures
and specialties namely, orthopaedics, radiotherapy; dental/maxillofacial, urology, and other
interventions. The number of CBCT scans and intervention complexity also control the range
Effects of ionizing radiation
The major deleterious effects of ionising radiations are primarily categorised into two
different types namely, stochastic and deterministic effects. The deterministic effects occur
when the exposure threshold is exceeded. Deterministic effect severity is directly
proportional to exposure dose. Some of the most common effects are cataract, sterility, skin
erythrema, and radiation sickness. However, the stochastic effects follow some linear-no-
threshold hypothesis that occurs due to ionising effects of symmetrical translocation. These
lead to cancer, and several hereditary defects such as, Down syndrome. The risk of cancer
development is found to follow some linear pattern with an increase in radiation dose (Palma
et al. 2013). The effective doses of ionising radiation are used for measuring them in terms
of their harm inflicting potential and are measured as Sievert (Sv) units. This unit also takes
into consideration the kind of radiation and organ or tissue sensitivity. The stochastic effects
of cancer appear several decades later and their likelihood is proportional to the dose of
radiation. One particular study suggested that 35.6% general private practitioners refer
CBCT. Oral radiologists (14.2%) and surgeons (21.9%) are found to be the frequent groups
who referred CBCT to the patients, followed by prosthodontists and orthodontists (Warhekar
et al. 2015). The technique is also referred for the use of conservative dentistry, oral
diagnosis, and general dentistry. Another study provided evidence for the fact that
periodontics (21%), prosthodontics (14%), and dental professionals with advance education
in dentistry (13%) were some of the most requested resident providers, with regards to use
of CBCT (Fewins 2017). The mean age of patient referrals was found to be 45 ± 21 years
with a predominance of 62% women. Most patient referrals were made from periodontolgy
specialists (17%) and maxillofacial surgeons (51%) (Arnheiter, Scarfe and Farman 2006).
Radiation protection
The use of the CBCT technique commonly spans a plethora of clinical procedures
and specialties namely, orthopaedics, radiotherapy; dental/maxillofacial, urology, and other
interventions. The number of CBCT scans and intervention complexity also control the range
3DENTISTRY
of doses. Radiation protection guidelines involve standard measurement of image quality
and doses across different manufacturers (Rawson 2015). Availability of aggregate dose is
recommended (Paul, Mbalisike and Vogl 2013) for equipment that are used in CBCT and
fluoroscopy. Reduction of dose include designing the CBCT equipment meeting the
mechanical and electrical safety requirements, containing electronic displays on the operator
consoles, and presence of low dose protocols. Selections of high dose protocols in cases
that involve visualisation of soft tissues such as, intracranial haemorrhage, abscess or
tumors are some of the guidelines (de Gonzalez et al. 2013). Creating a balance between
the exposure and the quality needs help in optimising radiation dose. Reduction of mA and
kVp for the equipment have been found to create no significant loss of the quality of images.
Another procedure for radiation protection encompass bringing about a reduction in the size
of X-ray beams to minimum needed size for imaging the object/organ of interest (Rehani et
al. 2015). This has been found effective in limiting the dose of harmful radiation exposure to
the patients, in addition to improving the quality of images by scatter reduction. Imaging
doses have been found to account for an estimated 2% or more of target doses, with respect
to first generation, linac mounted kV CBCT systems (SEDENTEX CT 2011). Thus, radiation
protection involves evaluation of the daily CBCT imaging for all patients, for sensitive organs
having lower thresholds for non-stochastic effects and pediatric patients having high
radiation sensitivity. Use of low-quality neurointervention scan protocols, typically using
fewer number of CBCT projections, are usually considered sufficient for producing high-
contrast structures such as, bony anatomy or contrast-enhanced vessels. Maintaining
sufficient distance from the source of x-rays and use of shields are also effective radiation
protection steps.
of doses. Radiation protection guidelines involve standard measurement of image quality
and doses across different manufacturers (Rawson 2015). Availability of aggregate dose is
recommended (Paul, Mbalisike and Vogl 2013) for equipment that are used in CBCT and
fluoroscopy. Reduction of dose include designing the CBCT equipment meeting the
mechanical and electrical safety requirements, containing electronic displays on the operator
consoles, and presence of low dose protocols. Selections of high dose protocols in cases
that involve visualisation of soft tissues such as, intracranial haemorrhage, abscess or
tumors are some of the guidelines (de Gonzalez et al. 2013). Creating a balance between
the exposure and the quality needs help in optimising radiation dose. Reduction of mA and
kVp for the equipment have been found to create no significant loss of the quality of images.
Another procedure for radiation protection encompass bringing about a reduction in the size
of X-ray beams to minimum needed size for imaging the object/organ of interest (Rehani et
al. 2015). This has been found effective in limiting the dose of harmful radiation exposure to
the patients, in addition to improving the quality of images by scatter reduction. Imaging
doses have been found to account for an estimated 2% or more of target doses, with respect
to first generation, linac mounted kV CBCT systems (SEDENTEX CT 2011). Thus, radiation
protection involves evaluation of the daily CBCT imaging for all patients, for sensitive organs
having lower thresholds for non-stochastic effects and pediatric patients having high
radiation sensitivity. Use of low-quality neurointervention scan protocols, typically using
fewer number of CBCT projections, are usually considered sufficient for producing high-
contrast structures such as, bony anatomy or contrast-enhanced vessels. Maintaining
sufficient distance from the source of x-rays and use of shields are also effective radiation
protection steps.
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