Vol. 106 No. 4 October 2008

ORAL AND MAXILLOFACIAL RADIOLOGY Editor: Allan G. Farman

American Academy of Oral and Maxillofacial Radiologyexecutive opinion statement on performing and

interpreting diagnostic cone beam computed tomography

The American Academy of Oral and Maxillofacial Ra-diology (AAOMR) is the professional organization rep-resenting oral and maxillofacial radiologists in theUnited States. The Academy is a nonprofit professionalsociety the primary purposes of which are to advancethe science of radiology, improve the quality and accessof radiologic services to the patient, and encouragecontinuing education for oral and maxillofacial radiol-ogists, dentists, and persons practicing oral and maxil-lofacial imaging in allied professional fields.

The AAOMR embraces the introduction of conebeam computed tomography (CBCT) as a major ad-vancement in the imaging armamentarium available tothe dental profession.

The AAOMR is currently in the process of develop-ing a position paper on appropriate application ofCBCT to provide evidence-based guidelines. In theinterim, the Executive Committee (EC) of the AAOMRconsiders it necessary to provide an opinion documentaddressing the principles of application of CBCT as itrelates to acquisition and interpretation of maxillofacialimaging in dental practice.

RECOMMENDATIONSThe AAOMR EC believes that the practitioner

should apply imaging procedures based on consider-ations of patient radiograph selection criteria, dose op-timization, technical proficiency, and assessed diagnos-tic or treatment needs. The following guidelines havebeen formulated to assist practitioners in providingappropriate CBCT radiologic care. These guidelines arenot inflexible rules or requirements of practice and arenot intended, nor should they be used, to establish alegal standard of care.

1. Use of CBCTCBCT imaging involves exposure of the patient to

ionizing radiation. CBCT should be performed only by

an appropriately licensed practitioner or certified radio-logic operator under supervision of a licensed practi-tioner with the necessary training. CBCT examinationsshould be performed only for valid diagnostic or treat-ment reasons and with the minimum exposure neces-sary for adequate image quality.

2. Practitioner responsibilitiesA practitioner who performs or supervises CBCT

examinations must hold a valid license. Dentists usingCBCT should be held to the same standards as board-certified oral and maxillofacial radiologists (OMFRs),just as dentists excising oral and maxillofacial lesionsare held to the same standards as OMF surgeons. It isthe responsibility of the practitioner obtaining theCBCT images to interpret the findings of the examina-tion. Just as a pathology report accompanies a biopsy,an imaging report must accompany a CBCT scan.

Practitioners who operate a CBCT unit, or requestCBCT imaging, should have thorough understanding ofthe indications for CBCT as well as a familiarity withthe basic physical principles and limitations of thetechnology. Practitioners should be familiar with alter-native and complementary imaging and diagnostic pro-cedures and should be capable of correlating the resultsof these with CBCT findings. Practitioners using CBCTmust have a thorough understanding of the operationalparameters and the effects of these parameters on imagequality and radiation safety.

It is desirable for practitioners to undergo specifictraining to perform CBCT examinations successfully.The practitioner who operates a CBCT unit, or requestsa CBCT study, must examine the entire image dataset.This is predicated on a thorough knowledge of CTanatomy for the entire acquired image volume, ana-tomic variations, and observation of abnormalities. It isimperative that all image data be systematically re-

viewed for disease. The field of view will vary with the

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system employed, positioning, and collimation, and caninclude intracranial structures, the base of the skull, theparanasal sinuses, the cervical spine, the neck, and theairway spaces. Qualified specialist OMFRs may be ableto assist diagnostically when practitioners are unwillingto accept the responsibility to review the whole exposedtissue volume.

There may be a misconception on the part of somepractitioners that the user has no responsibility forradiologic findings beyond those needed for a specifictask (e.g., implant treatment planning). This assump-tion is erroneous.

CBCT operators should only be individuals who arelegally permitted to perform CBCT procedures pre-scribed by a licensed dental practitioner. Such individ-uals may be employed by the dental practitioner or mayperform CBCT procedures in an independent facilitypursuant to all pertaining regulations. The CBCT oper-ator must have a thorough understanding of the oper-ating parameters of the CBCT system and the effects ofthese parameters on image quality and radiation safety.The CBCT operator has the responsibility for patientcomfort, preparing and positioning the patient for theCBCT procedure examination, monitoring the patientduring the examination, and obtaining the image data ina manner prescribed by the referring practitioner. TheCBCT operator should also perform calibration and theregular quality control testing.

Before delegating the operation of CBCT units, thedental practitioner must confirm the legal authority fortechnical performance of CBCT imaging in his or herspecific locality. As the CBCT system is considered tobe a medical device in some localities, a dental auxil-iary certified to perform dental radiographic proceduresmight not be qualified to perform CBCT.

3. DocumentationDocumentary evidence should be provided to dem-

onstrate the diagnostic or treatment guidance need ofthe CBCT examination. Appropriate demographic,clinical, and case history information should be avail-able to permit the proper performance and interpreta-tion of the CBCT examination.

To support the diagnostic necessity of the procedureand facilitate patient understanding, it is desirable thata separate patient consent be obtained for the CBCTprocedure before imaging.

To facilitate image retrieval, the dataset itself shouldbe stored in compliance with relevant legal and regionalstipulations and should be exportable in a format com-

patible with the International Standards Organization

(ISO)-referenced Digital Imaging and Communicationsin Medicine (DICOM) Standard. Distributed imagesare a component of the permanent record and should bestored in a suitable archival format. An interpretationreport of the imaging findings should also be includedin the patient’s record.

4. Radiation safety and quality assuranceFacilities operating CBCT should have specific pol-

icies and procedures for dose optimization. These in-clude, but are not limited to, custom examination ex-posure protocols taking into account patient body size,field limitation to the region of interest, and use ofpersonal protective devices such as a lead torso apronand, where appropriate, a thyroid collar. Proceduresshould follow all pertaining regulations.

The purpose of a quality control program is to min-imize radiation risk to the patient, personnel, and pub-lic, while sustaining adequacy of the diagnostic infor-mation obtained. The dental practitioner is responsiblefor the development of the program. The programshould include documentation of the performance ofcalibration tests, a log of the results of equipmentperformance monitoring, facility dosimetry results, anda legible chart of patient- and task-specific techniqueexposure parameters.

The AAOMR EC encourages the use of CBCT tech-nology within the practice of dentistry where this re-sults in health care benefits for the patient.

The above represents the collective statement of theAAOMR EC as approved without dissent. Dr. WilliamC. Scarfe was assigned the role of primary editor andcoordinator for development of this statement.

Laurie Carter, DDS, MA, PhDAllan G. Farman, BDS, PhD, EdS, MBA, DSc, DDS, MS

James Geist, DDSWilliam C. Scarfe, DDS

Christos Angelopoulos, DDSMadhu K. Nair, BDS, DMD, MS, Lic.Odont., PhD

Charles F. Hildebolt, DDS, PhDDonald Tyndall, DDS, MSPH, PhD

Michael Shrout, DMD, FAGDAmerican Academy of Oral and Maxillofacial

RadiologyExecutive Committee

P.O. Box 1010Evans, GA 30809-1010

doi:10.1016/j.tripleo.2008.07.007