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During the past 3 decades, technological innovation has brought tremendous improvements in high-definition 3D imaging and CAD/CAM processes that have helped dentists to diagnose and treat patients more accurately.1 From a clinical perspective, adopting new techniques that increase the precision in diagnosis and treatment is an important pursuit; however, practice owners and practice management staff need to understand the necessity of facilitating appropriate education along with the purchase of digital equipment. Digital literacy content is often lacking in the classroom settings of dental schools, and practicing dentists who are new to technological advancements are often expected to learn and train independently, as opposed to in an educational setting with support from experienced faculty, which does not always allow them to build optimal confidence in their skills.
Learning decision-making in the comfort of a classroom setting is important to build confidence in the use of new technology before using it on patients, particularly regarding patient safety and the avoidance of legal repercussions. A lack of sufficient supervised practice can impact a dentist's ability to make decisions when using imaging equipment, including cone-beam computed tomography (CBCT), and thus hinder him or her in achieving a proper return on investment for the technology, both financially and clinically. Furthermore, appropriate education is crucial for dental assistant students, dental hygiene students, and other dental imaging professionals in order to achieve the best return on investment for these technologies in states in which imaging can be performed by team members other than the dentist.
Best Practices for 3D Imaging
When compared with conventional imaging, the use of CBCT has been shown to significantly increase the detection rate of tooth root canal spaces and periapical areas for the evaluation of dental infection and other pathoses.2 Modern dental CBCT units produce 3D images that improve the accuracy of diagnosis and treatment planning for everything from orthodontics to implant dentistry,3 which can make a practice more efficient and productive. Moreover, following best practices is critical in order to avoid legal liabilities.
It is the responsibility of the dentist or the dental imaging professional to document why a CBCT image is necessary in the diagnosis or treatment planning of a patient's chief complaint. If there is no complaint, then the imaging professional should document the rationale used to justify the acquisition of the image as well as the amount of exposure involved, which should follow the as low as reasonably achievable (ALARA) and as low as diagnostically acceptable (ALADA) principles supported by the American Dental Association.4 The rationale for CBCT imaging, along with the licensed imaging professional's initials and the date, must be included in the patient's chart.
Reviewing a patient's previous radiographs and CBCT scans in his or her chart and history should be a part of the examination. A patient's record is a legal document and should provide clear documentation of each instance that he or she was seen in the office, why he or she was seen, and any imaging that was performed. For every case, a dental imaging professional, whether he or she is the dentist or not, is responsible for gathering and documenting the diagnostic imaging information. The data collected by the imaging professional should be clear and without errors.
Although learning how to engage with patients using effective communication strategies should be a priority of every dental healthcare professional, it can be particularly important for imaging professionals. In certain situations, nonverbal communication methods may need to be adapted and used in the office. Having patients use a pen or pencil to write down questions or answers can be helpful if you do not understand them or to gain more clarity. Reasons that patients may struggle to speak in a dental office can include pain, swelling, or trauma caused by an accident. Another effective communication strategy involves using 3D imaging software as a patient education tool. This software allows dental imaging professionals to digitally create treatment plans, document patient notes, and identify important landmarks for future treatment.
Digital technologies can positively influence organizational structure, but that influence depends on the specific process.5 If the staff utilizing a technology does not have institutional knowledge, the technology can compromise effectiveness. Differences in the relative distribution of expertise can constrain the structuring process, so appropriate education for any staff members involved in its use is essential. Regarding CBCT, if an office relies on one dental imaging professional, the workflow may be impacted. It is important for those who are acquiring scans to not only learn how to do it correctly but also understand the 3D views in the digital imaging software after the scan is taken.
Consequences of Inadequate CBCT Education
Too often, elongation, cone cuts, and other imaging errors occur that a dental imaging professional should have corrected for before exposing the patient. Education about radiography and related radiographic techniques should provide dental imaging professionals with sufficient practice to understand how to correct errors to avoid misdiagnoses. Similar errors can occur when utilizing CBCT. In California, recent disciplinary actions toward licensed imaging professionals include those related to a lack of or no documentation of the use of CBCT, missing initials from the documentation, failure to obtain a CBCT scan when indicated despite access to a CBCT machine, and misdiagnosis related to imaging. One licensed professional who faced disciplinary action from the state dental board had documented the chief complaint but obtained insufficient records during the first visit. In another instance, the state dental board investigated a complaint about an orthodontic case in which the patient underwent clear aligner therapy. The dentist owned a CBCT machine, but no scan was taken, and the case did not meet the standard of care required for professional diagnosis.
When implementing new technologies, such as CBCT imaging, dental professionals need to understand the intricacies of the communication patterns that accompany these innovations. These need to be developed within the office, and the responsibilities of the licensed professionals need to be clear. Extensive training in educational institutions or other programs can lead to a better understanding when practicing and learning new capabilities.
Implications of Learning Modalities
Regulations regarding which dental professionals are permitted to acquire CBCT scans vary by state. For example, in California, dental assistants are permitted to acquire radiographs, whereas in Maine, dentists are responsible for all imaging.6,7 As CBCT imaging makes its way to more dental practices, it is important for all team members who will be involved to become educated about the correct digital workflow within the office; however, the question is what is the best way to facilitate that?
Learning how to use new technology while in the job environment can create problems related to how trainees understand the software and interpret their roles within the organization.8 Meanwhile, distributed learning brings its own challenges when the content includes technology, including ensuring quality, cost-effective student support at scale.9 In a world characterized by technologies that allow experts to work with less assistance, shadow learning may play an increasingly significant role in helping trainees progress in their skills. Teaching computer-aided technology requires hands-on training with self-evaluation by the trainee and an evaluation from the trainer. Without optimal training, an increasingly small, hyperspecialized group can lose the skill to do the work effectively, and other practice employees do not know what they do not know.8 Furthermore, some institutions' simulations do not allow for any hands-on experience due to the cost of the equipment and other factors. The consequences of this in training include the need to increase engagement for trainees, premature specialization rehearsal in trainee performance, and unsupervised struggles without documentation.
Integrating more education about digital technologies into dental school curricula could help to substantially increase standards in patient treatment and disease prevention.10 Although digital technologies have become more prevalent in dental education, institutions face barriers to implementation in their curricula, and continued research into how best to accomplish this implementation is necessary.11 Regarding CBCT imaging, there is no standard curriculum or protocol for the provision of training.2 It has been asserted that students may be more motivated to use digital technology when they have both a strong grasp of it and a perception that others are using it effectively because they feel a sense of control over how it can impact their future practice.12
As such, postgraduate training options are important. A postgraduate educator's role is to support licensed professionals in understanding how to use effective communication strategies with patients, how to use a 3D imaging platform as an educational tool, and how to avoid operator errors using digital diagnostic equipment. The goal is to be able to provide a consistent workflow within the office that avoids misdiagnoses and enables dental healthcare professionals to effectively communicate treatment plans to patients by using intraoral and extraoral diagnostic images to tell a story.
When implemented correctly, the use of CBCT imaging can substantially improve practice efficiency and profitability via increased precision and predictability. Unfortunately, according to Jain and colleagues, "the lack of proper education and awareness among dentists is leading to unnecessary referrals for CBCT imaging."13 The key to the proper implementation of CBCT imaging is training. CBCT exposure should follow the ALARA and ALADA principles and be clinically justified for each patient. Older CBCT machine models mostly had large fields of view, which resulted in the production of more scattered radiation and contributed to the delivery of increased radiation doses to patients.13 However, software advancements in the optimization of today's CBCT scanners have reduced the radiation doses delivered by allowing users to choose from different field of view sizes. The usage of CBCT in dental practices has proven benefits for diagnostic clinical assessments, the identification of dental disease, and treatment planning.13 As dental school curricula continue to adjust to include evolving digital technologies, including CBCT, continuing education and postgraduate training modalities will continue to be of paramount importance in educating dentists so that they and their patients can reap the benefits.
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About the Author
Esther Cruz, RDA, MA, is the founder of Enlight.C.
1. FDI World Dental Federation. CAD/CAM Dentistry: adopted by the FDI General Assembly: August 2017, Madrid, Spain. Int Dent J. 2018;68(1):18-19.
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4. American Dental Association. Radiographic Imaging. ADA website. https://www.ada.org/en/resources/practice/practice-management/radiographic-imaging. Accessed August 24, 2023.
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6. Maine Board of Dental Practice. License and permit types. State of Maine Department of Professional and Financial Regulation website. https://www.maine.gov/dental/licensure/license-types.html. Accessed August 4, 2023.
7. Dental Board of California. Dental assisting table of permitted duties. California Department of Consumer Affairs website. https://www.dbc.ca.gov/formspubs/pub_permitted_duties.pdf. Revised October 3, 2018. Accessed August 4, 2023.
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