Commentary: Cone‐Beam Computed Tomography: An Essential Technology for Management of Complex Periodontal and Implant Cases

The advent of cone-beam computed tomography (CBCT) has become one of the most useful advances in periodontology. CBCT has the potential to streamline clinical workflow; enhance the periodontist's skills in diagnosis and complex treatment planning; hone surgical anatomic expertise; and improve outcomes in specific implant and periodontal cases. Periodontists are, and should continue to be, the leaders in applications of emerging technologies like CBCT, which enjoy widespread use but lack sufficient research that provides traditional evidence-based guidance to the clinician. The American Academy of Periodontology (AAP) recognizes the importance of continued development in these new fields as well as the need for clinical direction in the absence of definitive data. Consequently, the AAP used a model of scientific inquiry called “best evidence consensus” (BEC), which is grounded by best available current published evidence, with consensus expert opinion to guide reasonable additional uses in selected clinical scenarios. Two BEC meetings were conducted in 2017—one on CBCT and another on lasers. For each BEC topic, specific clinically relevant questions were developed, systematic reviews were written, and a panel of experts was convened to review findings and provide expert opinion to guide clinicians on “best practice” use of these evolving technologies. This issue of the Journal of Periodontology contains proceedings of the BEC on CBCT. Research on the use of CBCT continues to be published; however, the significant growth rate of this technology over the past 15 years is likely an indication that it may be critical to our practices. To maintain a leadership role in the application of CBCT technology, periodontists must remain abreast of continued research regarding its clinical benefits and limitations. The decision to integrate CBCT into practice is not to be taken lightly. Understanding what it can accomplish and its limitations is critical. Implementation can be costly in terms of the equipment purchase and the required time investment for clinician and staff to become properly trained, not only in the nuances of the machines, but also in critical decision making as to when taking a CBCT is appropriate. The BEC papers on CBCT technology in this issue are excellent references for new clinicians considering a CBCT unit and for seasoned clinicians evaluating how their current protocols align with the currently accepted state of the art. While implant reconstruction represents its most common use, CBCT has become an important tool in the armamentarium of many specialists. Our continued team approach to comprehensive patient treatment with general dentists, oral and maxillofacial radiologists, and other specialists will allow us to increase our knowledge of clinical indications for CBCT. The AAP Best Evidence Consensus papers1-4 reviewed the current and diverse ways CBCT applies to patient care, and experts provided their opinions on the following specific clinical questions regarding CBCT use: Question 1. Should CBCT imaging replace two-dimensional (2D) radiographic analysis of regional anatomy in the surgical management of patients requiring dental implants? To address this question, three major areas were identified and reviewed. Indications included CBCT use for: 1) diagnosis and treatment outcome assessment; 2) implant treatment planning; and 3) anatomic characterization. There is considerable literature that supports CBCT use in all three areas. The clinical bottom line determined by the expert panel was that CBCT has diverse applications for dental implant therapy and should be used as an adjunct to 2D radiology when the specific benefits to the patient outweigh the risks. Some key areas that support CBCT use include sinus grafting preliminary evaluation, surgical guide fabrication, and location of relevant anatomic structures and their relation to the proposed implant placement. Question 2. Is CBCT imaging useful in determining risk to periodontal structures in patients requiring tooth movement? The literature demonstrates that changes occur to the buccal plate and general alveolar bone structure with tooth movement. Experts on the BEC panel agreed that CBCT is the only radiographic modality with which such changes can be objectively detected and preoperative risk determined. While there is limited evidence to support CBCT as a routine part of periodontal-orthodontic therapy, experts agreed on several scenarios where CBCT should be considered. The best examples include patients with a thin dentoalveolar phenotype and those with concomitant recession. Other examples where some knowledge exists, but more research is warranted, include preventative soft tissue and bone augmentation indications and adult versus child applications. Question 3. Does CBCT imaging add clinical value in diagnostic assessment and treatment planning for the management of periodontitis? According to current evidence, a 2D full-mouth radiographic series combined with clinical probing remains the gold standard for comprehensively evaluating periodontal structures. However, experts on the BEC panel identified several situations where the addition of CBCT imaging would be useful, including: 1) when advanced furcation lesions have been detected and dental implants are being considered as an alternative treatment option; and 2) when there is a questionable root fracture, root resorption, or periodontal-endodontic lesion present that could not be clearly identified by 2D imaging and/or clinical evaluation. Minimally invasive therapies and evaluation of regenerative procedure outcomes are two areas of potential benefit where further research was indicated. This commentary has provided a brief review of some of the key findings from the BEC meeting on clinical use of cone-beam computed tomography; the state-of-the-art reviews and expert consensus document can be found in this issue. These papers are intended to guide periodontists in their daily practice and are a must-read for those involved in patient care. As the expert panel concluded, CBCT is a useful and widely available tool that has the potential to improve today's standard of care. The valuable three-dimensional (3D) views CBCT provides can significantly change the course of treatment. Additionally, new imaging software is rapidly enhancing the use of CBCT, making it a more intuitive, effective tool for virtual treatment planning. As an added benefit, the digital file format of CBCT scans is easily transferable when working with referrals. Research demonstrating the value of CBCT is ongoing; however, 3D imaging is supplanting traditional radiographic methods in certain clinical scenarios. The wealth of literature evaluated and the expert opinions generated during the BEC meeting on CBCT (and others to follow) enable the AAP to provide guidance on emerging tools of the profession. Ultimately, however, each clinician must assess the benefits and limitations of the technology and the readiness of the practice in determining whether it is appropriate to incorporate these innovations. The American Academy of Periodontology Best Evidence Consensus meeting on cone-beam computed tomography was sponsored by Carestream Dental (Atlanta, Georgia). Dr. McAllister has received lecture fees from Carestream Dental. Dr. Eshraghi reports no conflicts of interest relative to this commentary.