ORAL HEALTH EVIDENCE-BASED PRACTICE PROGRAM
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Title Cone-Beam Computed Tomography (CBCT) Is Not Indicated as a Routine Replacement or Adjunct to Intraoral Full-Mouth Series Radiographs in the Diagnosis and Management of Periodontitis
Clinical Question For patients with periodontal disease, does CBCT in assessing periodontal destruction, as compared to conventional 2D radiographs, provide greater value to formulate a more accurate diagnosis and prognosis and effective treatment plan?
Clinical Bottom Line For patients with periodontal disease, the current evidence does not support use of CBCT as a primary diagnostic tool or routine adjunct to the current gold standard of conventional 2D full mouth series radiographs combined with a thorough clinical periodontal evaluation, in the diagnosis and management of periodontitis.
Best Evidence (you may view more info by clicking on the PubMed ID link)
PubMed ID Author / Year Patient Group Study type
(level of evidence)
#1) 28967334Kim/201712 studies, 221 patientsSystematic Review
Key resultsThe increased radiation exposure and costs associated with 3D imaging do not justify its use for routine diagnosis and treatment planning in the management of moderate-severe periodontal disease. While CBCT affords clinicians better visualization of intrabony and furcation defects, it lacks significantly superior short- or long-term clinical outcomes as part of standard diagnostic protocol and treatment planning. At this time, clinicians should use 3D imaging within a limited scope to evaluate specific teeth and/or regions to enhance treatment planning and therapy.
#2) 28967333Mandelaris/2017n/aConsensus Statement
Key resultsThis best evidence consensus from the American Academy of Periodontology is based on the Kim/2017 systematic review and affirms: 1) The gold standard for comprehensive periodontal evaluation is 2D full-mouth radiographic series with a thorough clinical periodontal exam. 2) There is insufficient evidence to support routine use of CBCT in periodontal diagnosis and treatment planning. 3) CBCT adds value on an individual patient basis and for interdisciplinary approaches, including useful 3D imaging for the following scenarios (according to expert opinion): • Detecting advanced furcation lesions impacting dental implant treatment planning. • Evaluating advanced bone loss encroaching on anatomic structures (e.g. sinus cavity). • Determining root fracture, root resorption or periodontal-endodontic lesions, after they could not be identified by 2D imaging or clinical evaluation. • Retreatment of cases unresponsive to localized periodontal therapy.
#3) 26669748Walter/20167 studies, 100 patientsSystematic Review
Key resultsCBCT effectively detects vertical bony defects; however, it is not indicated to routinely assess intrabony defects. It also accurately identifies furcation involvement and the associated periodontal morphology, especially in maxillary molars, and is advantageous for complex treatment planning and invasive procedures. However, given the higher radiation dose compared to 2D radiographs, CBCT should be used on an individual case basis and according to ALARA principles (As Low as Reasonably Achievable).
Evidence Search ("periodontal diseases"[MeSH Terms] OR ("periodontal"[All Fields] AND "diseases"[All Fields]) OR "periodontal diseases"[All Fields] OR ("periodontal"[All Fields] AND "disease"[All Fields]) OR "periodontal disease"[All Fields]) AND ("cone-beam computed tomography"[MeSH Terms] OR ("cone-beam"[All Fields] AND "computed"[All Fields] AND "tomography"[All Fields]) OR "cone-beam computed tomography"[All Fields] OR ("cone"[All Fields] AND "beam"[All Fields] AND "computed"[All Fields] AND "tomography"[All Fields]) OR "cone beam computed tomography"[All Fields])
Comments on
The Evidence
VALIDITY: The systematic reviews were based on an extensive search and quality control selection for inclusion. The reviews relied entirely on case series studies and would have more strength if they included RCTs. Neither of the reviews allowed for meta-analysis due to either an inadequate number of clinical studies or heterogeneity in the reported outcomes. PERSPECTIVE: Based on the evidence, CBCT should be considered an advanced diagnostic tool capable of very accurately elucidating detailed diagnostic data, and not for routine use in the initial evaluation, treatment planning, and management of periodontitis alone. These reviews used only clinically based studies; however, they did not consider patient outcomes. Further research and/or a new systematic review with consideration of patient outcomes following treatment plans based on either imaging technique (2D, CBCT) would give additional clarity on more effective and safe application of CBCT as well as better cost-benefit determination.
Applicability CBCT and 3D imaging inarguably enables highly accurate visualization of various anatomic structures and morphologies for any discipline. It also proves advantageous in the assessment of pathology and development of complex, interdisciplinary treatment plans. However, given the cost-benefit ratio for patients and clinicians, the current evidence still reinforces 2D full-mouth series radiographs with a thorough clinical evaluation as the gold standard in the routine evaluation and management of periodontitis. Since no one patient is absolutely the same as another, providers are expected to develop treatment plans and utilize modalities specific to each patient’s unique circumstances. This especially applies to more advanced diagnostic and treatment options, which should only be considered based on the patient’s needs and after initial, lower risk methods fail to either provide the required information or correct the disease/condition. Considering the higher costs and radiation exposure which accompany CBCT over intraoral and panoramic radiographs, its routine use for the diagnosis and management of periodontitis is not justified at this time.
Specialty/Discipline (Public Health) (Oral Medicine/Pathology/Radiology) (Endodontics) (General Dentistry) (Oral Surgery) (Orthodontics) (Pediatric Dentistry) (Periodontics) (Prosthodontics) (Restorative Dentistry)
Keywords cone-beam computed tomography; CBCT; periodontal diseases; diagnosis
ID# 3274
Date of submission: 10/16/2017spacer
E-mail lunams@livemail.uthscsa.edu
Author Dr. Michael S. Luna
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