Professional Education in CBCT

Transcription

1 Professional Education in CBCT Hugh Devlin

2 Where do you get information? 1. GOOGLE 2. WIKIPEDIA 3. JOURNALS eg DMFR but we are all busy people

3 Recent New York Times article Refers to a JADA issue devoted to CBCT but. This article was paid for by the manufacturers. Journals have been accused of bias

4 Instruction in CBCT is not provided as part of the undergraduate dental curriculum. In future a requirement for CPD in reading 3-D images but there is no agreed core curriculum. Large FOV machine images of non dento-alveolar structure are required to be reported!

5

6 So why should I be interested in CBCT? Internet says 1. DIAGNOSTIC QUALITY 2. SHORT SCAN TIME 3. RADIATION DOSE LESS THAN CONVENTIONAL CT

7 DIAGNOSTIC QUALITY 1. 3-D image dependant on good QA HPA guidelines Some measurements require a phantom Large differences in noise between devices useful quantitative analysis of bone quality requires low noise and good image uniformity

8 Quality assurance PHANTOM one has been developed as part of SedentexCT

9 Image quality assessment must be comprehensive As well as correct X-ray equipment function Practical Radiation Technique Patient dose Image processing and viewing No standard protocols for clinical image quality assessment for CBCT. The QA programme should entail surveys and checks

10 Internet said SHORT SCAN TIME But shorter than what? Is it that important? Most time spent explaining and setting up the patient for the scan

11 But is comparison with conventional CT scan realistic? UK Health Protection Agency

12 It is not appropriate to take a CBCT examination SOLELY to reconstruct a panoramic or cephalometric radiographic view So what EXTRA does CBCT provide that a dentist might need and want? Implantologists and orthodontists are targeted by manufacturers (young patient risk!) CBCT image is not recommended routinely in orthodontic practice. Therefore, the decision making in oral radiology is a balance between the risk assessment and the diagnostic information needed. (Silva et al, 2007)

13 MANUFACTURER S WEBSITE Orthodontic Planning: insufficient training to interpret radiographs beyond the confines of their specialty but they are obligated to read all of the film

14 Where do I get help?...is it difficult? 1. German CBCT guidelines Dentale Volumentomographie (DVT) S1-Empfehlung. 2. Danish CBCT guidelines (2009)..are in broad agreement 3. Norwegian guidelines Maxillofac Rad is not a recognised specialty in some countries

15 Cone Beam CT Training Courses are available Heath Protection Agency A course on 26 July 2011 at HPA Radiation Protection Division, Centre for Radiation, Chemical and Environmental Hazards, Chilton, Didcot, Oxon

16 Getting started Directive 96/29/Euratom (1996) laying down basic safety standards This source document is where we start to think about training Directive 97/43/Euratom (1997) on health protection of individuals Patient protection appropriate training for the staff involved Individual member States to enact appropriate provisions to ensure compliance

17 UK Health Protection Agency Guidelines currently little guidance available for dentists to inform them of the different radiation protection requirements. Up until SedentexCT in 2008 there was no guidance on training European Academy of Dental and Maxillofacial Radiology Basic Principles for use of dental CBCT (2009).

18 Basic Principles EADMFR recognised an urgent need to set standards for CBCT use Set up a Guideline Development Panel to develop a set of draft statements resulted in a set of 20 Basic Principles

19 EADMFR Basic Principles on the use of CBCT 16. All those involved with CBCT must have received adequate theoretical and practical training Continuing education and training after qualification are required, particularly when new CBCT equipment or techniques are adopted. 18. Dentists responsible for CBCT facilities who have not previously received adequate theoretical and practical training should undergo a period of additional theoretical and practical training that has been validated. 19. For dento-alveolar CBCT images of the teeth a radiological report should be made by a specially trained DMF Radiologist or, where this is impracticable, an adequately trained general dental practitioner.

20 Problems 1. Few suitably qualified experts able to deliver face-toface educational opportunities, 2. Many CBCT users may be widely scattered geographically. provide e-learning standard, high quality

21 What training priorities do we need for CBCT? Involved all stakeholders 1. Internet questionnaire to EADMFR members 339 members with 282 valid addresses. 139 replies 2. Internet questionnaire to European Federation of Organizations for Medical Physics. 28 physicists replied. 3. Internet questionnaire to manufacturers. 4 replied.

22 Preliminary designs for needs analysis formulated by SedentexCT members Web survey content was divided into several elements: Needs analysis what training? Methods of delivering training Methods of assessment of users Background data on respondents The questionnaire was piloted amongst participants in the SedentexCT consortium

23 What training was wanted? Rank EADMFR survey (principally dental radiologists) Rank EFOMP/ Medical Physicist survey 1 Information about Radiation doses and risks of CBCT 1 An objective technical comparison of different CBCT machines 2 A Quality Assurance Programme for users of CBCT 2 = Information about Radiation doses and risks of CBCT 3 A strategy for Radiation Protection of patients 2 = A Quality Assurance Programme for users of CBCT 4 A strategy for Radiation Protection of staff 4 Information about Quality Control Test Tools for CBCT 5 = Anatomical CBCT reference image library 5 A detailed technological description of how CBCT works 5 = Pathological CBCT reference image library 6 A strategy for Radiation Protection of patients 7 Evidence-based Referral/ Selection Criteria for 7 A strategy for Radiation Protection of staff CBCT 8 Dose Maps for CBCT 8 Dose Maps for CBCT 9 Descriptions of the Dental clinical uses of CBCT 9 An image library of faults on CBCT images 10 = Information about Quality Control Test Tools for CBCT 10 A regularly updated database of links to scientific publications on CBCT 10 = An image library of faults on CBCT images 11 Evidence-based Referral/ Selection Criteria for CBCT

24 Manufacturers views of website content Manufacturers survey Greatest need Descriptions of the Dental clinical uses of CBCT Descriptions of the Oral and Maxillofacial Surgery clinical uses of CBCT Evidence-based Referral/ Selection Criteria for CBCT An image library of faults on CBCT images Descriptions of the non-dental (e.g. imaging of sinuses, middle ear) clinical uses of CBCT A Pathological CBCT reference image library A regularly updated database of links to scientific publications on CBCT. An objective technical comparison of different CBCT machines Information about Radiation doses and risks of CBCT An Anatomical CBCT reference image library A list of available CBCT equipment on the market A detailed technological description of how CBCT works A strategy for Radiation Protection of staff A strategy for Radiation Protection of patients Information about Quality Control Test Tools for CBCT Least Need Pictures of available CBCT equipment on the market Links to manufacturers websites A Quality Assurance Programme for users of CBCT Dose Maps for CBCT A history of the development of CBCT technology

25 We distilled these needs into a core curriculum 1. How does CBCT work? 2. Principles of radiation dose and risk? 3. Justification: net benefit 4. Referral criteria 5. Radiation dose: optimization for patients and staff 6. Radiation dose: quality assurance 7. Anatomy 8. Interpretation of pathology

26 The website

27

28 Brainstorming over the net How does CBCT work - Part 1 Ideas for content Principles of imaging - how you get the volumetric data (Malmo - all) Comparing 2D and other 3D principles of imaging (Malmo - all) Ideas about the nature of the training materials Use a story approach (patient examination) (Malmo - all) Look for problems for the learner to solve (Malmo - all) Draft Learning Objectives KNOWLEDGE AND UNDERSTANDING Understanding of how x-rays interact with material Knowledge of the concept of the imaging chain from initiating the x-ray exposure to display of the image Understanding of the difference between 2D and 3D imaging Understanding of the basic structure and function of a CBCT machine SKILLS AND ABILITIES none JUDGEMENT AND STANCE to attain an excellent understanding of the fundamental basis of all X-ray imaging

29 Radiation dose and risk Module KNOWLEDGE AND UNDERSTANDING Knowledge of the effective doses associated with CBCT and other dental X-ray techniques. A basic understanding of how the effective dose of CBCT is influenced by equipment and patientrelated variables (introduction to optimisation). SKILLS AND ABILITIES to be able to communicate doses and risks of CBCT to staff and to patients effectively. JUDGEMENT AND STANCE to achieve an evidence-based understanding of dose and risk associated with CBCT that can be communicated to others in easily understood language.

30 We then developed 1. Wiki 2. Newsletters 3. Diagnostic forum modules with Powerpoints (with voiceover)

31 Ensuring that stakeholder requests for training are available in the training materials DENTISTS PHYSICISTS Information about Radiation doses and risks of CBCT An objective technical comparison of different CBCT ppt Module machines Wiki A Quality Assurance Programme for users of CBCT Information about Radiation doses and risks of CBCT Wiki ppt Module A strategy for Radiation Protection of patients ppt Module A strategy for Radiation Protection of staff.ppt Modules on Dose optimization and justification Anatomical CBCT reference image library ppt Module A Quality Assurance Programme for users of CBCT Wiki Information about Quality Control Test Tools for CBCT Wiki A detailed technological description of how CBCT works ppt Module

32 Wiki

33 SedentexCT Forums:

34 The Future. SedentexCT Training EADMFR

35 Demonstration of Website by Gareth Hughes

36 And finally New Guidelines from SedentexCT due out next week!!

37 Statements derive from a combination of Basic principles and European Directive - All those involved with CBCT must have received adequate theoretical and practical training for the purpose of radiological practices and relevant competence in radiation protection ED BP Others require a consensus amongst EADMFR members - CBCT applications specialists and agents of manufactures and suppliers of CBCT equipment who provide information and training to clinical staff should obtain relevant training in radiation protection and optimization