The question of whether a Cone Beam Computed Tomography (CBCT) scan is mandatory before initiating root canal treatments or endodontic surgery is increasingly pertinent in modern dentistry. While many endodontists are equipped with CBCT technology, it’s crucial to evaluate if routine scanning genuinely serves the best interests of patients and aligns with the standard of care.
To gain perspective, it’s important to consider the global landscape of dentistry. Although CBCT units are prevalent among endodontists in the United States, this is not universally the case. Many dental professionals worldwide lack access to CBCT scanners and still rely on traditional multiple angle radiographs. CBCT technology offers a significant advancement by providing 3-D visualizations of the patient’s anatomy, eliminating the limitations of 2-D images like overlapping structures and distortion. Dentists often utilize CBCT scans obtained from radiology offices to distinguish pathology from normal anatomical structures. However, the critical question remains: has CBCT imaging become the new standard of care in endodontics?
Defining the Standard of Care in Dental Practice
In legal terms, the standard of care is defined as “what a reasonable health care provider would or should do under similar circumstances.” This definition is central to understanding when and why CBCT scans might be considered necessary.
Most practitioners concur that CBCT scans are highly beneficial, and in certain scenarios, indispensable prior to endodontic surgery. The precision offered by CBCT imaging is particularly vital in surgical procedures that involve delicate anatomical areas, such as sinus cavities, nerve canals, or blood vessels. CBCT scans excel at revealing intricate anatomical details, spatial relationships, traumatic fractures, missed canals, resorptions, and complications arising from instrumentation, like perforations. The detailed measurements obtained from CBCT can sometimes reduce the need for additional working radiographs, potentially offsetting the higher radiation dose associated with CBCT.
The Impact of CBCT on Diagnostic Accuracy and Treatment Decisions
3-D imaging has been shown to enhance diagnostic capabilities, identifying up to 40 percent more lesions that might go undetected with traditional 2-D imaging. This increased detection rate raises important questions about treatment protocols. Does identifying more lesions automatically translate to a 40 percent increase in endodontic procedures? Research by Pope et al. indicates that the periodontal ligament (PDL) width in healthy teeth can naturally vary from 0.2 to 1 mm (1). This variability prompts us to consider potential biases in interpreting CBCT scans, especially when a widened PDL is observed in a tooth that has undergone root canal treatment. Are we over-treating teeth based on findings that might be within the spectrum of normal anatomical variation, or are we potentially negligent by not addressing lesions identified through advanced imaging?
Legal Implications and the Use of CBCT Technology
In the context of potential legal disputes, a patient must demonstrate that negligence during treatment directly caused their injury. Courts will assess whether the treatment provided adhered to the accepted standard of care (2). Legal issues can also arise from perceived deficiencies in care. For example, failing to document a patient’s refusal of a recommended CBCT scan before a surgical procedure could be detrimental in a legal case. Malpractice is often considered in situations where a negative outcome could have been prevented by utilizing appropriate technology and clinical expertise.
This is where the strengths of CBCT imaging become particularly relevant. CBCT aids in preventing complications by providing a comprehensive view of the scanned region’s anatomy. However, it’s important to remember that CBCT scans involve a higher radiation dose compared to a limited series of digital periapical radiographs. Therefore, the recommendation is to reserve CBCT for cases where there are clear diagnostic and treatment benefits, including follow-up assessments. Studies have shown that CBCT imaging significantly influences treatment planning. Approximately half of clinicians who referred patients for CBCT scans modified their initial treatment plans based on the findings. Furthermore, about 30 percent of practitioners opted for active intervention instead of observation, and in some cases, proceeded with tooth extraction after reviewing CBCT images (3).
The interpretation of periapical health or disease can be viewed as a spectrum. There’s a tendency to consider retreatment when a radiolucency appears to be of medium size on radiographic images. Teeth might appear adequately filled and healed on traditional periapical radiographs, yet CBCT scans could reveal over-extended obturation with an associated widened PDL. Considering patient-centered outcomes, it’s important to evaluate whether retreatment in such cases truly enhances the patient’s quality of life and oral health. While some argue for retreatment to address these findings, a valid counter-argument suggests that in certain situations, non-intervention combined with radiographic monitoring remains a viable and appropriate approach (4).
Conclusion: CBCT as a Tool, Not a Universal Standard
In conclusion, to address the initial questions, CBCT may indeed be considered the standard of care for specific endodontic therapies, particularly in surgical and complex diagnostic scenarios. However, it is not universally required for every root canal treatment. CBCT is not intended as a routine screening tool. Clinicians could face legal repercussions for not ordering a CBCT scan if such imaging could have prevented patient harm. Conversely, they could also face legal challenges for failing to document informed refusal when a CBCT scan is recommended but declined by the patient. In situations where CBCT is deemed beneficial, thorough documentation is crucial. When in doubt about the necessity of a CBCT scan or a patient’s decision, detailed written documentation is always advisable.
References
- Pope O, Sathorn C, Parashos P. A comparative investigation of cone-beam computed tomography and periapical radiography in the diagnosis of a healthy periapex. J Endod 2014;40:360-5.
- Curley AW. Dentistry, the law and CBCT. 2016 [cited; Available from: http://www.dentaleconomics.com/articles/print/volume-106/issue-10/science-tech/dentistry-the-law-and-cbct.html
- Mota de Almeida FJ, Knutsson K, Flygare L. The effect of cone beam CT (CBCT) on therapeutic decision-making in endodontics. Dentomaxillofac Radiol 2014;43:20130137.
- Liang YH, Li G, Wesselink PR, Wu MK. Endodontic outcome predictors identified with periapical radiographs and cone-beam computed tomography scans. J Endod 2011;37:326-31.
