CBCT and clinical decision-making
Arvind Sharma, BDS(Dund), MSc(Endo), MJDFRCS(Eng), MFDSRCPS(Glas)
Arvind Sharma presents the second and final part of a structured critical review to evaluate the question whether the use of cone beam computed tomography (CBCT) in endodontics has an influence on clinical decision-making.
The methodology of this review is based on the aforementioned steps, as suggested by Boland et al 2014. Below is a brief summary of the methods used.
The following structure was therefore employed:
- Inclusion criteria
- Exclusion criteria
- Search engines
- Search strategy with literature search
- Study selection
- Quality assessment
- Data extraction.
The topic considered was discussed with my supervisor and also with my peers to solicit their views.
The author attended a British Endodontic Society conference held in London in March 2015 and met Dr Patel (one of the speakers that day) when the topic of this review was discussed.
The author and Dr Patel corresponded by email, and Dr Patel suggested that there is a lack of evidence in this field due to lack of clinical studies and suggested that a systematic review would be difficult in his opinion. This led the author and his supervisor to consider a structured critical review instead.
Due to the aforementioned reasons and since the author’s time and resources are limited, a traditional systematic review was not possible. It was decided, therefore, to design and conduct a structured critical review of the literature to answer the question posed.
|F&T Level||Studies Identified|
|3-Diagnostic Thinking Efficacy||4|
|5-Patient Outcome Efficacy||1|
Table 4: Summary of included studies with associated F&T hierarchy levels
The review question was then formalised as a statement of my intention of the structured critical review. This was developed from what was found through the available evidence to what I further planned to find out. A theoretical approach, exploring factors that lead to a process, was to be taken.
The search identified eight publications that qualitatively or quantitatively assessed the use of CBCT in endodontics combined with clinical decision-making with respect to three levels of a six-tiered hierarchical model. (Level 3 diagnostic thinking efficacy, Level 4 therapeutic efficacy and Level 5 patient outcome efficacy).
The following table (table 3), shows the final eight papers that were included in this study along with the F&T hierarchy levels.
As can be seen from the above table (table 4), four papers were identified investigating the diagnostic thinking efficacy, three papers investigating the therapeutic efficacy and one paper investigating patient outcome.
Of all the eight studies, six concluded that CBCT made an influence in clinical decision-making and two did not.
A meta-analysis was not performed. Only a narrative summary of the data is presented since the included studies did not meet the criteria for conducting a meta-analysis. The differences across the trials, including inconsistent patient characteristics presented in some of the papers, small sample sizes, diversity in protocols (interventions and comparators were not uniform across all studies), and the inconsistency in reporting outcomes (not all studies reported the same results), including statistical data (not present in one study), precluded a statistical synthesis of the included trial results.
The aim of this structured critical review was to answer the question, “does the use of CBCT in endodontics influence clinical decision making?” Of the eight studies chosen for this review, 75 per cent concluded that CBCT did influence decision-making whereas 25 per cent of studies concluded that CBCT did not influence clinical decision-making.
From the evidence analysed in this review, CBCT appears to have a positive influence in clinical decision-making in endodontics. However, when data was extracted, the six studies (75 per cent) did show limitations, which will be discussed below.
Although the literature search provided an abundance of evidence on CBCT, the evidence available relating to the review question was limited. When considering the hierarchy of evidence (randomised controlled trials being the most robust form of study) and application of the inclusion criteria to the results of the searches there was a lack of studies in this area with only nine studies meeting criteria. One of the reasons for this is due to ethical considerations in relation to the exposure of patients to radiation when taking a CBCT for an in-vivo trial/study. So, although CBCT is being more commonly used in clinical endodontic practice, the number of in-vivo studies is lacking. This was further confirmed by personal communications with the well-published author and committee member of the European Society of Endodontology, Dr Shanon Patel.
The limited literature search was further compounded by the fact that Fryback and Thornbury Levels 3, 4 and 5 were applied and this resulted in fewer relevant studies. A number of studies were found but were mainly on levels 1 (technical quality of image) and 2 (diagnostic accuracy, sensitivity and specificity). The inclusion criteria of human, English language and in-vivo studies again limited the number of studies since published animal and foreign language studies were excluded. Applying a search for ‘all studies’ gave a wider net for the search with non-relevant studies due to their hierarchical level of evidence being excluded. This was the case with Kurt et al 2003, which was a cross-sectional observational study.
Considering the available studies, the author believes that all or at least a representative sample of the available evidence relating to the study question was obtained.
|Study||Study Title||F&T Levels|
|1. Abuabara et al 2012||Efficacy of clinical and radiological methods to identify second mesiobuccal canals in maxillary first molars||3|
|2. Balasundaram et al 2012||Comparison of Cone-beam computed tomography and periapical radiography in predicting treatment decision for periapical lesions: |
a clinical study
|3. Davies et al 2015||The detection of periapical pathoses using digital periapical radiography and cone beam computed tomography in endodontically retreated teeth-part 2: |
a one- year post-treatment follow-up
|3 + 4|
|4. Ee et al 2014||Comparison of endodontic diagnosis and treatment planning decision using cone-beam volumetric tomography versus periapical radiography||4|
|5. Hashem et al 2015||Clinical and radiographic assessment of the efficacy of calcium silicate indirect pulp capping: a randomised controlled clinical trial||3|
|6. Kurt et al 2014||Outcomes of periradicular surgery of maxillary first molars using a vestibular approach: a prospective, clinical study with one year of follow-up||5|
|7. Mota de Almeida et al 2014||The impact of cone beam computed tomography on the choice |
of endodontic diagnosis
|8. Mota de Almeida et al 2014||The effect of CBCT on therapeutic decision-making in endodontics||4|
Table 3: The final eight papers included in this study
Overall, on a hierarchy of evidence, since only two randomised controlled trials were included, the evidence gathered was not of the highest calibre. The included studies all had limitations that were either discussed by the individual authors or were identified during this review’s quality assessment process. The limitations identified included, small sample sizes in most studies, history and clinical information (signs and symptoms) not always provided, the number and clinical experience of observers varied from novice to most skilled, the radiation dose used with the CBCT modality was not always validated, the resolution of CBCT images was not always discussed as image enhancement may or may not have affected the image quality and hence results and detailed statistical data were not disclosed in three studies.
In one study where periradicular surgery was being performed, a microsurgical approach was not used, which is now accepted as the gold standard in retrograde endodontics, both in Europe and North America. The ability, for example, to identify artefacts due to beam hardening that could be misdiagnosed as a carious lesion is an important point. Therefore, image interpretation is still an area that requires further training especially for less experienced clinicians.
There were limitations with this structured critical review study with respect to the time that was spent on the literature search, the final selection of the chosen studies, the quality assessment and data extraction. This was mainly due to the part-time nature of this study and there only being one individual, namely the author, executing the various stages of this structured critical review.
It is the author’s opinion that by having more than one individual working on various aspects of this study, bias may have been eliminated, leading to a more rigorous study process.
The limitations were related to the methodological part of this study. Specifically:
- Inclusion/exclusion criteria-language bias, publication bias was considered in a limited way with the use of one researcher
- Literature search resources – three search engines only being employed
- Search strategy – one researcher, using mainly electronic databases only and study selection
- Quality assessment only being performed by one researcher
- Data extraction only being performed by one researcher and was not cross-checked by another person. However, data was put aside for one week and then checked again to compare that the sets of the data were the same.
With all of the above limitations considered, it is the author’s opinion that a thorough and reproducible literature search was performed using appropriate and relevant search terms, quality assessment of the chosen studies enabled the most appropriate studies to be used for data extraction purposes and since the conclusions reached for this critical review process are similar to other reviews in this field of study, the author is confident that the review process was conducted with appropriate methodology, is clear, reproducible, thorough and transparent.
Although the overall findings of this review seem to suggest that CBCT is influential in clinical decision-making, it is the author’s opinion that the findings cannot be generalised and applied to the everyday clinical practice of endodontics. There was disparity in the studies in terms of their design, sample size, age range, male-female ratio, setting, sample definition, F&T level, examiners used (experience and number of) and use of statistical data, which means it is difficult to make an absolute comparison of outcomes and reach a definitive conclusion based on the chosen studies. CBCT does have an important place in endodontic clinical decision-making but its use should still be limited as ESE recommend.
In conclusion, this critical review has shown that although most of the available evidence appears to show that CBCT does influence clinical decision-making in endodontics, high-quality longitudinal studies are lacking, and more research is required. Based on the current available evidence, the ESE guidelines seem appropriate and should be applied accordingly. The studies by Balasundaram et al 2012, Davies et al 2015 and Mota de Almeida et al 2014 all looked at the detection of periapical radiolucencies and, as discussed earlier, did not concur with their results. CBCT has a useful place in clinical decision-making in endodontics but its use should be kept for complex cases where radiographs do not give sufficient information. This would resonate with the ESE guidelines.
As discussed earlier, there are implications in using CBCT, namely, cost of equipment, training required for the use and interpretation of CBCT and importantly the radiation dose the patient is exposed to. No doubt, CBCT can be relevant and useful in endodontics and can have an influence in clinical decision-making, which in turn may help a patient with complex symptoms that routine investigative methods have proved limited. However, the overall consensus of the studies do not recommend the routine use of CBCT in endodontics but recommend its consideration when other methods of diagnosis prove to be inconclusive in reaching a definitive diagnosis. Again, this would in line with guidelines produced by the ESE. Looking into the future, if CBCT equipment can expose the patient to less radiation, perhaps in line with the amount produced by intra-oral radiographs, its use may well increase particularly if coupled with a more affordable price tag. Increasing CBCT education at undergraduate and postgraduate level would improve knowledge and application in the clinical setting. This would ultimately give the clinician more tooth detail, which could in turn improve patient care and the reputation of endodontics as a dental discipline amongst patients.
This structured critical review has shown that there is limited evidence on the influence of CBCT in clinical decision-making in endodontics. The available evidence does however seem to suggest that there is a place, although limited, for CBCT use in endodontics with decision-making. Application of ESE guidelines should be followed until further research can be carried out in this interesting and clinically relevant imaging modality
Verifiable CPD questions
Aims and objectives
To give the reader an understanding of CBCT as a modern imaging tool and its application in endodontics
To provide details of the evidence surrounding clinical decision making in endodontics
To highlight the clinical applications where use of CBCT in endodontics would be advantageous
To understand the basics of how CBCT works
and its clinical application in endodontics
To be able to recognise when the use of CBCT
may help clinical decision-making
What kind of process was used to carry
out the research?
a) Systemic review?
b) Randomised controlled trial?
c) Structured critical review?
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