Cone Beam Computerised Tomography ebook

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I asked my boss to buy a CBCT machine.

We were an NHS practice with 6 surgeries and a velopex chemical processor for x-ray film; there was no way he was going to do that. I offered him the chance for me to pay, to buy the machine itself and pay for half the revenue to him in an associate contact, but amazingly he still refused.

It would be 2009 before I got my first CBCT machine of my own, but it was worth the wait. It changed my practice forever.

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Introduction

It must have been in the early 00’s when I began to use medical CT for my dental implant patients. I was aware of this thing that people were doing abroad, where CT machines were coming into dental practices but didn’t quite understand it. I was also aware of a company called IDT who were encouraging dentists to send their patients to hospitals to have their CT scans taken.

I remember well, treating an older lady with the intention to put implants into her posterior mandible and I couldn’t see where the nerve was on a panoramic x-ray, but I knew it was close. I was put in touch with a consultant radiologist from Queens Medical Centre in Nottingham called Alan (a wonderful man) and the next thing I knew I was in his office looking at huge, wobbly film sheet (I still have them for this case) of a lady’s mandible that I had no way of interpreting.

Alan said to me “we can’t quite see the nerve on these scans” and I was horrified. The patient had paid hundreds of pounds for this and I expected that it would cure everything.

Isn’t this the way, we always expect that new technology will be simple to use and provide all the solutions, and it never does.

Despite that, that case made the curtain come up. I could see the advantages, I could see how it could enhance my practice, I could see how it could change the way that I did dentistry.

I asked my boss to buy a CBCT machine.

It would be 2009 before I got my first CBCT machine of my own, but it was worth the wait. It changed my practice forever.

The Three Stages of CBCT so Far

First stage imaging

In the early days, in the mid – late 00’s, CBCT was exploding and the point was to get an image in 3 dimensions. In those days it didn’t matter, this was the first stage imaging. It didn’t matter about the dose, nobody paid attention to this. It didn’t really matter about the field of view (people were having their whole head scanned all the time), what mattered was that you could get a 3-dimensional image and even put an implant in electronically. Patient’s went nuts, it set you apart from the crowd.

Field of View

After 2009, it became possible to buy machines that would take CBCT’s in different Fields of View, this meant that you didn’t have to fry a patient, or radiate their whole head to get a shot for just one single site. It became more acceptable for CBCT to be taken for more and more dental implant cases and other treatment modalities including trauma, endo and impacted teeth.

The third age

The third age has only recently begun, which is to chase the dose of CBCT down. The ultra-low dose age of CBCT is here, and now it is possible to take an upper arch CBCT of good quality for about the same of 3 periapical x-rays. We await the fourth age.

How Regulation Never Caught up

CBCT exploded around 2010-11 and has continued ever since. It has become a commoditised market where everyone is looking for a cheaper option, but sadly the regulation of CBCT and the training associated with it never caught up. Other countries are much further ahead, but here, it is still possible to buy a CBCT machine put it in and do a tick box exercise to say you’re trained how to use and interpret it. That is simply not good enough and is one of the things that this e-book is about.

Remember the Patient Comes First

While we all agree that it is cool to have fantastic technologies, and I think there is no doubt that CBCT has enhanced practice and overall made implant dentistry and some oral surgery procedures safer, we must remember the hippocratic oath and to ‘first do no harm’.

In the early stage of CBCT, where all we had was the chance to take full skull CBCT’s for patients, people were doing it for a single implant in a UR4 region. That was, and is not, acceptable. We all must take great care to make sure that we’re only using CBCT’s which are clinically justified and acceptable under the principle of limiting radiation to patients.

As is often the case, sadly many people saw it as a business opportunity, to kick out as many CBCT’s for as many reasons as possible and predictably the price dropped as it commoditised. People then fought harder and took more CBCT’s. The same thing happened with OPG machines in the 1990’s, when as soon as an OPG machine dropped into an NHS practice, everybody got an OPG whether they needed it not (that was only some practices).

Throughout this and thinking that taking CBCT’s for patients for individual treatment modalities, it’s essential to get back to the ethical practice of taking it for the patients benefit and not for anything else.

Our Journey Through the CBCT Landscape

In 2009, I purchased my first CBCT machine, the Carestream 9000. Overall this was an extraordinary purchase, and it changed the way I did dentistry. The machine itself was restricted to small Field of View (4 x 5cm) for a full arch, it was possible to take three separate CBCT scans and ‘stitch’ the images together to give a full arch. This was a little bit unpredictable at times but worked generally quite well.

It wasn’t good enough for guided surgery though, and the stitching was too inaccurate for this.

The image quality for the Carestream CBCT was brilliant but lately I have discovered that that is because the dose was the highest out of all the CBCT’s I have ever used. I used to present on data given to me by Carestream about how low the dose was, but it seemed that this was not entirely the case. When we go back to discuss dose a little bit later on you will see that it is a difficult minefield for practitioners to navigate. That said, the Carestream machine served us well for five years, although it did have a reputation for the sensor in the machine to break; I was aware of two machines in close proximity to me whose sensors broke and needed to be replaced for £20,000 a time.

It wobbled when it moved, but the software was easy to use. We took 100’s and 1000’s of CBCT’s with that machine. I went to the practice recently where the CBCT machine went when I sold it in 2014 and it still going strong. It’s done very well.

Interestingly though in 2009 when the machine was installed we only had 1 hour of training with the technician who installed it, and we were away. The first CBCT I took I didn’t even capture the jaw, and I’m not sure exactly what it radiated.

In 2014, we changed machine and system to Sirona 3D XG. This was a machine that was to take us to guided surgery, together with this we paid £90,000 to buy a full Cerec system to allow us to mill surgical guides in-house.

We were way ahead of the curve on this and were milling the first Cerec 2 guides in the UK.

The Sirona machine was as solid as a rock with a 5-year guarantee (I loved that for budgeting). It meant that if the machine would break it would be fixed free of charge. It was classic German engineering, but the resolution and image quality was very, very disappointing. The dose was too high and the image quality that we got throughout the life of that machine was disappointing in comparison to the image quality of Carestream; although the dose was lower than Carestream.

You see now the conundrum we start to reach, ethical healthcare practitioners increase the dose to the patient for a better-quality image, or decrease the dose for a lower quality image. Which is acceptable? How low is still acceptable?

I ran the Sirona machine for nearly 5 years, but in the end, the image quality, the changes in digital dentistry, and the opening up of all other systems meant it was feasible to move to another system to try to reduce the dose for the patient and increase the image quality. So, in late 2018 we moved to a Planmeca Pro Max CBCT.

The Planmeca Pro Max is a much more multi-functional machine than that of which we had before. We can alter and vary the settings enormously to increase the dose for better imaging or to decrease the dose for safer patient imaging. We have an ultra-low dose mode which we’re using almost routinely, which gives us a very good image, the dose of just a few periapical radiographs has now expanded the use for CBCT in practice for us.

No system or machine is without teething difficulties or issues, merging some of the Planmeca files for guided surgery has been a challenge, but one that we have overcome and been able to use routinely on a day-to-day basis. It means that I have no dose issues now taking CBCT’s for patients and I’m even at the stage of taking post-op sinus graft CBCT’s and likely taking post-op CBCT’s for large implant placement cases.

This is linked to the Romexis software of Planmeca which is the best software of all the systems that I have used.

There are other machines on the market of course, Vatech, Gendex, and all have benefits, advantages and disadvantages. We now though, are one of the only practices I’ve never known to run multiple CBCT machines and to have a much clearer insight into the market place, the sales processors and some of the guff that is talked about in CBCT.

Choosing Your own CBCT

For you though, how do you choose, and how do you navigate the minefield of CBCT manufacturers?

Firstly, it’s important to understand exactly what you’re going to use it for and secondly, you have to look at the budget case for a CBCT and whether it is worth it. Thirdly, you have to decide if you want it to be cheap, or you want it to be good, and fourthly, you’ll want to cross reference that against people who have been there who are open and honest and who will talk about things in a clear way which allows you to pick the best machine that is right for you.

Points you need to consider

1. Guarantees

2. Servicing

3. Image quality

4. Dose

5. Ease of use

6. Software provided

7. Support provided

8. Longevity

9. Your overall business case

We’re always happy to chat to people who are interested to look at CBCT.

My advice would be to spend some time on dudigilance and to speak to people who have been in the system for a long time.

Be aware of cognitive distance. Many people who have spent tens of thousands of pounds on a piece of kit are not happy to tell you about the disadvantages of them because they think it reflects badly on them. I am happy to talk to anybody about the advantages and disadvantages of all three CBCT systems that I have had, and the others that I have worked with in other practices in other places.

Software Problems

When you’re considering your CBCT, or once you have brought it, the biggest thing you will interface with is the software that reconstructs your image.

These days this is less important because it’s possible to take the DICOM (digital imaging and communications in medicine) file and put it into any open software. What does that actually mean though. It means that you can take the DICOM file, which has to be open so that the patient does not need to be irradiated again, and place it into any other software platform that will accept DICOM. There are now many open software platforms which are free, or get their revenue from clicks at a later stage of a design process, so you don’t have to be concerned as much as previously that the software that comes with your machine is the best on the market. You can report your scan in other software, and you can discuss with experienced individuals which software you would like to use. That said, to me, software is important and the generic software is designed to work with the sensor when the machine collects the image.

All the software’s have benefits and disadvantages and none that I have ever seen are seamless. Some things you might want to look for in your software are as follows:

1. Implant aligned view

If you’re using your software to place implants you want to be able to centre all the different slices around the implant that you have placed, to do this with one click of a button provides you with an amazing insight into the planning process.

2. The ability to report in MPR (Multi plane radiography)

This is a legal requirement, you should be reporting in MPR as it is the truest and most accurate reporting format, but not one which is familiar to dentists in the way that they view images. That is why it is so important to be well trained in the interpretation of CBCT.

3. Speed of reconstruction (you don’t want to wait 10 minutes for your scan to come through)

4. Ability to import DICOM’s into your software from other systems

Sirona was locked for the longest time, and I suspect it still is. That caused us no end of problems when people were sending us other CBCT files that we could not import into Sirona.

Make sure you get a demonstration of the software.

Guarantee Issues

A CBCT machine will be one of the biggest spends you will ever make in practice, and you are the customer. Before you get the money, you have all the power and after you spend it you have very little or none. Make sure you nail down a ‘service level agreement’ in one form or another. Sirona provide 5 year guarantees and Planmeca have provided us with the same on the machine that we now have. Other companies provide less and charge for the increase guarantee, that is an interesting concept. You may pay less for a machine and then have to pay more for the guarantee.

Remember there are two things that go wrong in a CBCT machine

1. The x-ray generator

2. The sensor

Both of those are expensive pieces of kit that require to be fixed, and while they’re broken you cannot take any images, CBCT or OPG. Nail down your guarantee early and know that the market is competitive. People will move heaven and earth to get your business, you should make sure you use that to get the best possible service and guarantee deal you can in advance of a purchase.

What to Use it For

As part of the process of deciding to invest in a CBCT machine, or CBCT training you have to decide and appreciate the things that you could use it for. CBCT has become synonymous with dental implant treatment and that is fair enough, but the advantages of having a CBCT machine for diagnosis for your patients in any other areas must not be overlooked. CBCT machines can be used to image patients in the following circumstances:

1. Dental implant planning and complications

2. Oral surgery planning and complication

3. Endodontics

4. Dental pathology assessment including cysts and impacted teeth

5. Trauma

6. Some aspects of pre-orthodontic treatment

Once you have the ability to access, and particularly to interpret CBCT’s appropriately (this is hugely valuable) you can expand your reporting and capabilities into areas which can benefit your patients enormously; and also lead to the correct and extensive uses of CBCT within your practice.

Understanding how to adapt the indications and report them is a fundamental way of not only enjoying your work with CBCT immensely but also ensuring the financial viability of the system within your own environment.

The Business Case for CBCT

Sadly, as in many areas of work, CBCT’s have become commoditised and people have overlooked the enormous intellectual property that exists in the ability to report radiography and in particular CBCT effectively and accurately.

CBCT’s have been driven down to the £100 and below mark. In many areas of the country the competition is stuck at £99 an image.

To go below this is to be unable to pay for the machine itself, and therefore to have a machine within your own business is a vanity project.

The value in CBCT, as in much professional intellectual property, is in the interpretation of the images, not the collection. It’s fine to make sure you’ve done a course that ticks the box to say that you’re legal (even though the regulatory bodies are way behind) but it’s much better to learn how to interpret CBCT’s within a group of people who understand it and who are happy to talk about this time and time again to assist learning.

David Beckham did not become good at free kicks by going on a one-day course telling him how to take them. He practiced and failed and practiced again, the same applies to any aspect of clinical practice. The foundation for this is competency-based training where you’re given the mind set to interpret scans in a particular way and then reflect on that and improve in your interpretation. This means that the setting of the price of your ‘product’ in practice must be set in two ways. First, the acquisition of the scan itself. This is cheap as it can be carried out in any scan centre. Second, the report of the scan, this is expensive because it reflects entirely on your time and intellectual property. The time and cost you spend on training, and the time and cost you spend interpreting. It also reflects the risk you take in providing a professional interpretation of a situation for a patient, much like the advice given by a lawyer.

Once you have a handle on this, and have decided not to compare your charges to anyone else in the area or beyond, you can set an appropriate fee for the scan and the report and then work out the business case for whether you can afford a scanner. As a classic example, if you obtain a 5-year guarantee for your scanner, you shouldn’t have to pay if it breaks. If the scanner costs £40,000 in total it means there is £8,000 of cost over those 5 years each year for the scanner itself. Remember that you may want to train yourself and probably your nurses to take scans, there will also be costs in doing this. There will be routine and general maintenance associated with the scanner and the IT associated so, if the overall cost of running the machine was £10,000 a year you can divide that number by the number of scans you intend to take. If you take 5 scans a month, it means your scans would need to be priced at £167 a scan to break even, anything over and above this is profit based on that simple calculation. In order to warrant a charge of more than £99 you must have expertise in reporting and be able to demonstrate and tell that story.

That is where CBCT training comes in, and that is where high-quality competency-based interpretation CBCT training is required.

What is Next For CBCT?

In early 2018, I was given the chance to travel to Planmeca Headquarters in Helsinki to see some innovative new developments on the horizon. I was able to plan dental implant procedures in virtual reality and also look at navigational dental implant placement opportunities; these things are already on the horizon. Ultra-low dose procedures will mean CBCT will become more widely accepted and reduction in Field of View will mean that it will be used for more treatment modalities including caries diagnosis, endodontic procedures and beyond.

The difficulties with this, is that it takes time to interpret CBCT scans, and takes much longer to do this than a periapical radiograph.

We must avoid the race to the bottom and protect our intellectual property by explaining to patients the wonderful benefits of new technologies available.

The future is bright and will only get better, but we must use it ethically and responsibly.

Why not consider The Campbell Academy competency based CBCT interpretation course which gives you the opportunity over 3 days to investigate CBCT interpretation and deeper at high level?