CDA Journal - May 2021: Oral and Maxillofacial Imaging by California Dental Association

Journa C A L I F O R N I A

D E N TA L

May 2021 Quality Assurance X-ray Safety Cone Beam CT and Endodontics California Oral Health Briefing

A S S O C I AT I O N

Oral and Maxillofacial Imaging: Evolving Technologies and Paradigm Shifts Sanjay M. Mallya, BDS, MDS, PhD

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Vol 49 Nº 5

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May 2021

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d e pa r t m e n t s

283 Guest Editorial/Hope for a Cavity-Free Generation 285 Impressions 353

RM Matters/Treating Elderly Patients: Minimize Risk With Informed Consent and Updated Health History

355 Regulatory Compliance/Radiation Safety Checklist 358 Tech Trends

f e at u r e s

289 Oral and Maxillofacial Radiology: Evolving Technology and Paradigm Shifts An introduction to the issue.

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Sanjay M. Mallya, BDS, MDS, PhD

291 Applying the New ADA Quality Assurance Standard to Digital Intraoral Radiographic Systems This paper provides examples to help clinicians recognize many of the problems encountered in digital intraoral radiography. Peter Mah, DMD, MS; Allison Buchanan, DMD, MS; and Teresa E. Reeves, DDS, JD, Col, USAF, DC

301 Effective and Safe Use of X–Rays: Understanding the Risks for Practical Decision-Making When prescribing radiologic imaging, dentists must ensure that the anticipated benefits of imaging will outweigh the radiation-associated risks of cancer induction. Sanjay M. Mallya, BDS, MDS, PhD

311 Cone Beam Computed Tomography and Radiographs for Endodontics: A Pictorial Illustration of the AAE-AAOMR Position Statement This pictorial essay elaborates the recommendations in the joint position statement of the American Association of Endodontists/American Academy of Oral and Maxillofacial Radiology through illustrated case scenarios to help clinicians understand the impact of CBCT on diagnosis and treatment planning. Rumpa Ganguly BDS, DMD, MS, and Mike Sabeti, DDS, MA

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Journa C A L I F O R N I A

published by the California Dental Association 1201 K St., 14th Floor Sacramento, CA 95814 800.232.7645 cda.org

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D E N TA L

Management Peter A. DuBois Executive Director Carrie E. Gordon Chief Strategy Officer Kristine Allington Chief Marketing Officer Alicia Malaby Communications Director

Editorial

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John L. Blake, DDS Vice President vicepresident@cda.org

Ruchi K. Sahota, DDS, CDE Associate Editor

Carliza Marcos, DDS Secretary secretary@cda.org Steven J. Kend, DDS Treasurer treasurer@cda.org Debra S. Finney, MS, DDS Speaker of the House speaker@cda.org Richard J. Nagy, DDS Immediate Past President pastpresident@cda.org

Brian K. Shue, DDS, CDE Associate Editor Gayle Mathe, RDH Senior Editor

Volume 49 Number 5 May 2021

A S S O C I AT I O N

Blake Ellington Tech Trends Editor

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The Journal of the California Dental Association (ISSN 1942-4396) is published monthly by the California Dental Association, 1201 K St., 14th Floor, Sacramento, CA 95814, 916.554.5950. The California Dental Association holds the copyright for all articles and artwork published herein.

Steven W. Friedrichsen, DDS, professor and dean, Western University of Health Sciences College of Dental Medicine, Pomona, Calif. Mina Habibian, DMD, MSc, PhD, associate professor of clinical dentistry, Herman Ostrow School of Dentistry of USC, Los Angeles Robert Handysides, DDS, dean and associate professor, department of endodontics, Loma Linda University School of Dentistry, Loma Linda, Calif. Bradley Henson, DDS, PhD , associate dean for research and biomedical sciences and associate professor, Western University of Health Sciences College of Dental Medicine, Pomona, Calif. Paul Krebsbach, DDS, PhD, dean and professor, section of periodontics, University of California, Los Angeles, School of Dentistry Jayanth Kumar, DDS, MPH, state dental director, Sacramento, Calif. Lucinda J. Lyon, BSDH, DDS, EdD, associate dean, oral health education, University of the Pacific, Arthur A. Dugoni School of Dentistry, San Francisco Nader A. Nadershahi, DDS, MBA, EdD, dean, University of the Pacific, Arthur A. Dugoni School of Dentistry, San Francisco Francisco Ramos-Gomez, DDS, MS, MPH, professor, section of pediatric dentistry and director, UCLA Center for Children’s Oral Health, University of California, Los Angeles, School of Dentistry Michael Reddy, DMD, DMSc, dean, University of California, San Francisco, School of Dentistry

The Journal of the California Dental Association is published under the supervision of CDA’s editorial staff. Neither the editorial staff, the editor, nor the association are responsible for any expression of opinion or statement of fact, all of which are published solely on the authority of the author whose name is indicated. The association reserves the right to illustrate, reduce, revise or reject any manuscript submitted. Articles are considered for publication on condition that they are contributed solely to the Journal of the California Dental Association. The association does not assume liability for the content of advertisements, nor do advertisements constitute endorsement or approval of advertised products or services.

Avishai Sadan, DMD, dean, Herman Ostrow School of Dentistry of USC, Los Angeles

Brian J. Swann, DDS, MPH, chief, oral health services, Cambridge Health Alliance; assistant professor, oral health policy and epidemiology, Harvard School of Dental Medicine, Boston

Visit cda.org/journal for the Journal of the California Dental Association’s policies and procedures, author instructions and aims and scope statement.

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Harold Slavkin, DDS, dean and professor emeritus, division of biomedical sciences, Center for Craniofacial Molecular Biology, Herman Ostrow School of Dentistry of USC, Los Angeles

Richard W. Valachovic, DMD, MPH, president emeritus, American Dental Education Association, Washington, D.C.

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327 Oral Health of California’s Children: A Commentary on the Status and Future Directions Jayanth Kumar, DDS, MPH, and Jared Fine, DDS, MPH

331 Oral Health Status of Children: Results of the 2018–2019 California Third Grade Smile Survey Brendan Darsie, MPH; Shannon Conroy, PhD, MPH; and Jayanth Kumar, DDS, MPH

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337 Development of an Interprofessional Education Event To Improve Dental and Pharmacy Students’ Attitudes Toward Interprofessional Collaboration This study assessed 119 second-year pharmacy and dental students’ knowledge and attitudes toward interprofessional collaboration before and after a two-hour curricular event held in May 2017. Erin Richards, DDS; Paul Gavaza, PhD; Farnoosh Zough, PharmD, BCPS; Jennifer Mathew, MA; Alireza Hayatshahi, PharmD, BCPS

345 Findings in Oral Health: Attitudes and Quality of Life Among Patients Experiencing Homelessness The goal of this study was to evaluate access to dental care, oral health attitudes, oral health-related quality of life and satisfaction with received dental care among people experiencing homelessness. Hazem Seirawan, DDS, MPH, MS; Laura Elizondo, DDS; Niel Nathason, MPH, MS; and Roseann Mulligan, DDS, MS

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Guest Editorial

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Hope for a Cavity-Free Generation Jayanth Kumar, DDS, MPH

Editor’s note: A colleague recently asked me, “Exactly what is it that the dental director does?” With that question, I knew it was time for the CDA Journal to more formally introduce the California Dental Director, Dr. Jay Kumar. CDA has worked closely with Dr. Kumar on several Journal issues since he took up his position in 2015, and also on oral health access projects and most recently on COVID-19 guidance. He has been a tireless advocate for improved oral health in our state and a wonderful partner and advocate for practicing dentists, especially in this pandemic. I have invited Dr. Kumar to introduce himself and give us a glimpse of his inspiration and his aspirations. In this issue, we begin a recurring section entitled California Oral Health Briefings. The goal of this collaboration is to increase the understanding of the oral health of Californians and to help public health and private practice dentists realize the importance of working together to achieve a level of oral health in our state that is unmatched elsewhere. We are grateful as residents of the state of California and as members of the California Dental Association that we have the benefit of a dental director like Dr. Kumar.

— Kerry K. Carney, DDS, CDE

We need a commitment to find a better solution, which may require substantial investments in research and technology to find a cure within five years — something akin to a moonshot program.

n the late ‘90s, I listened to Rob Reiner giving a speech at the American Association of Public Health Dentistry annual meeting. He discussed a campaign to pass Prop 10, the California Children and Families Initiative, which created First 5 California, a program of early childhood development services, funded by a tax on tobacco products. Reiner’s ideas resonated with me and gave me the vision to free young children from cavities. I envisioned a “Free by 3” campaign composed of a series of milestones in three-year increments. First, all 3-year-old children should be cavity free; three years later, when children enter kindergarten, they should be cavity free; and three years after that, when we measure tooth decay in the third grade, we should see substantial progress in their overall oral health. This will put a generation of children on a lifelong trajectory to achieve good oral health, thereby eliminating oral health disparities. I was looking for an opportunity to make this vision a reality and had read about the California Dental Association’s Access Report. It reflected the understanding that “there must be a realistic, comprehensive approach to solutions, focusing resources where they are most likely to have substantial impact and initially setting up a foundational

structure that will contribute to the success of subsequent recommendations.” The report focused on building the infrastructure and capacity to establish a foundation for public oral health programs, optimizing early disease prevention and health promotion efforts through policies and system changes, promoting approaches to increase oral health literacy and expanding the capacity to provide care to at-risk populations. I saw the opportunities to achieve my vision in California because of initiatives such as First 5 and the Kindergarten Oral Health Assessment requirement as well as a commitment to improve access to dental care. To translate that vision into a reality requires collective action. In the last five years, I have worked with our partners to create the structure to support it. The Office of Oral Health uses the collective action framework, which consists of five conditions — a common agenda, shared measurement systems, mutually reinforcing activities, continuous communication and a backbone organization. The California Oral Health Plan 2018–2028 offers the structure for collective action to assess and monitor oral health status and disparities, prevent oral diseases, increase access to dental services, promote best practices and advance evidence M AY 2 0 2 1

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based policies. Funding for the Office of Oral Health to serve as the backbone organization comes from the California Healthcare, Research and Prevention Tobacco Tax Act of 2016. Publishing data and reports in the Journal of the California Dental Association establishes a means for continuous communication. The California Smile Survey gives me hope that a cavity-free generation of 3-yearold children is a possibility. In this Journal issue, Darsie et al. report a 10 percentage point reduction in tooth decay prevalence since the previous survey in 2004–05. However, there are profound disparities with respect to the prevalence of tooth decay and untreated tooth decay. Over the last 20 years, the Alameda County Healthy Kids Healthy Teeth Program and the San Francisco Oral Health Collaborative have led the state in improving children’s oral health. Both local health jurisdictions created strategic plans, built partnerships and implemented interventions. In San Francisco, the prevalence of tooth decay in kindergarten children declined an impressive amount: from 60% in 2000–01 to 32% in 2017–18. However, the disparities in oral health are persistent, with tooth decay prevalence among children of color being three times higher compared to their Caucasian peers (greater than 35% versus 12%). What are the ongoing obstacles to achieving oral health equity? Is it because the impact of economic or community conditions prevents parents from complying with the recommendations to brush twice a day, feed kids a healthy diet and start dental visits early? Is it because of an overreliance on the clinical services? Is it because we don’t know the root causes of the disease? As I reflect upon the COVID-19 pandemic, I am impressed with the remarkable scientific progress that has been made in a short amount of time. Within the space of a year, the complete genome sequences of the novel SARS-COV-2 virus 284 M AY

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have been identified, numerous tests have been developed, a new vaccine mRNA platform was used to develop innovative vaccines, clinical trials involving thousands of people were conducted, remarkable vaccines with 100% efficacy to prevent deaths were developed, a new monoclonal antibody therapy is available and several drugs are being tested. Yet there has been no such focus to address the age-old global problem of tooth decay. A researcher at the National Institute of Dental Research (NIDR) told our class at Johns Hopkins in 1979 that there would be a caries vaccine in five years! Forty-two years later, we still don’t have a vaccine. Is it because of disparate interests, lack of coordination or inadequate resources? Or is it because caries is not an “attractive” problem to solve that will lead to media attention and celebrity? The only tool we have is fluoride, which is under intense attack. The best intervention to prevent and arrest tooth decay in young children is silver diamine fluoride (SDF), which I was using as a student 40 years ago. Silver nitrate was not popular back then because it stained teeth, and we still haven’t solved this staining problem! We do not have an objective test to identify children at high risk or a test to differentiate between active and arrested caries lesions. We need a commitment to find a better solution, which may require substantial investments in research and technology to find a cure within five years — something akin to a moonshot program. The last time such a commitment was made was in 1948 when the National Dental Research Act created the NIDR to address oral diseases. In the meantime, we should use the tools we have to make progress toward achieving the vision of a cavityfree generation:

Introducing toothbrushing in early care and education programs. ■ Enforcing the kindergarten assessment law. ■ Supporting the implementation of the proposed California Advancing and Innovating Medi-Cal (Cal/ AIM) Dental initiative. ■ Implementing structured nutritional counseling. ■ Exploring dental and primary care integration by supporting an electronic platform to complete referrals and assist with care coordination. ■ Supporting dental teams’ clear communication capacity to enhance oral health literacy. The second edition of the Surgeon General’s Report on Oral Health is expected to be released in 2021. I remain hopeful that the new report will articulate a vision for the future and call upon dentists and all Americans to take action against the burden of oral disease. n ■

Jayanth Kumar, DDS, MPH, is the state dental director, Office of Oral Health and the Center for Healthy Communities, California Department of Public Health.

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Soothing Dental Care Anxiety in Children With Autism For many people, the sensory environment of the dental clinic is familiar and routine. But for children with autism spectrum disorder (ASD), the sensations can be overwhelming, making it hard to receive regular dental care and putting them at risk for poor oral health. Dominique Como, an occupational therapist and a National Institute of Dental and Craniofacial Research (NIDCR)-supported PhD student from the University of Southern California (USC), and her colleagues are evaluating sensory adaptations to the dental environment that can help to reduce anxiety in children with ASD. The research is especially timely, because ASD appears to be on the rise. Since 2000, the prevalence of ASD has climbed from 1 in 150 to 1 in 54 children in the U.S., indicating that a growing number of dental practitioners are encountering these patients. However, studies have shown that many dental providers feel unqualified to work with patients with special needs. “Dental clinic visits can be incredibly taxing for the child, the parent and the dental practitioner,” said Como. “I want to find ways to make this a better experience for everyone.” With NIDCR support, Como and her colleagues give suggestions for addressing these challenges in a recent review article featured in a special issue of the International Journal of Environmental Research and Public Health. The strategies described in the article provide a blueprint for reducing dental treatment barriers for ASD patients. The article makes the case for collaborations among dental clinicians and specialists such as occupational therapists who can contribute their expertise and help dental providers learn to identify and accommodate ASD patients’ needs. Citing their own NIDCR-supported study at USC as an example, the authors describe how interdisciplinary teams are creating a sensory-friendly experience for children with ASD. Strategies such as removing bright lights and loud noises, adding calming music, and covering children with a weighted blanket that simulates a firm hug can be calming and help prevent sensory overload. New environments and unpredictable situations can also distress children with ASD. For their study, the USC team developed a social story with real-life photographs of a child receiving care in the dental clinic. Before a visit, parents were asked to read the stories to their children to help them prepare for the upcoming dental activities. Visual aids that break down procedures step-bystep may also help children with ASD prepare for dental visits. While Como and her colleagues are still evaluating the strategies’ effectiveness, families have described the interventions positively and reported some success in enhancing their children’s oral care. Como also encourages clinicians to seek the expertise of parents, who can help tailor strategies to their child’s unique needs. Read more of this study in the International Journal of Environmental Research and Public Health (2020); doi.org/10.3390/ijerph18010135. n M AY 2 0 2 1

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School-Based Dental Program Reduces Caries Low Rate of COVID-19 in Dental Hygienists Despite having been designated as high risk for COVID-19 by the Occupational Safety and Health Administration (OSHA), a new study finds 3.1% of dental hygienists have had COVID-19 based on data collected in October 2020. This is in alignment with the cumulative infection prevalence rate among dentists and far below that of other health professionals in the U.S. The research, published by the Journal of Dental Hygiene, is the first large-scale collection and publication of U.S. dental hygienists’ infection rates and infection control practices related to COVID-19. In partnership, the American Dental Hygienists’ Association (ADHA) and the American Dental Association (ADA) have released initial findings from their ongoing, joint research designed to estimate the prevalence of COVID-19 among U.S. dental hygienists as well as examine infection prevention and control procedures and any associated trends, including employment data. The data reflect results from the first month of a longitudinal study on the impact of COVID-19 on dental hygienists in the U.S. As of Oct. 8, 2020, a total of 4,776 dental hygienists from all 50 states and Puerto Rico had participated in the survey. Of the survey participants, 149 respondents (3.1%) had ever been diagnosed with COVID-19, either through testing or by a medical professional, and they were not clustered in any particular geographic region. More than 99% of respondents reported their primary dental practice had enhanced 286 M AY

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A school-based caries prevention program involving nearly 7,000 elementary school students reduced caries by more than 50%, according to a study led by researchers at the NYU College of Dentistry. The findings were published March 1 in the Journal of the American Dental Association. The study was conducted in 33 public, high-need elementary schools in Massachusetts, where dental hygienists provided care to 6,927 children. The services were provided at no cost to families. Twice-yearly visits involved dental examinations followed by caries prevention and treatment, including fluoride varnish, sealants and minimally invasive fillings to stabilize cavities without drilling. Students also received oral hygiene instructions, toothbrushes and fluoride toothpaste to take home. If more complex care was required, students were referred to local dentists. Notably, the procedures used do not create aerosols, which limits the risk of transmitting viruses through the air. After six visits, the prevalence of untreated caries decreased by more than 50%. In one group of schools, caries was reduced from a baseline of 39% to 1%; in a second group, caries decreased from 28% to 10%. The prevention program reduced caries in both deciduous and permanent teeth. Recent economic analyses of school-based caries prevention programs by researchers at the NYU College of Dentistry, including one focusing on this program in Massachusetts, demonstrate that they are cost-effective and could save federal dollars. “The widespread implementation of oral health programs in schools could increase the reach of traditional dental practices and improve children’s oral health — all while reducing health disparities and the cost of care,” said Richard Niederman, DMD, professor and chair of the department of epidemiology and health promotion at the NYU College of Dentistry and the study’s senior author. Learn more about this study in the Journal of the American Dental Association (2021); doi.org/10.1016/j.adaj.2020.12.005.

infection prevention or control efforts in response to the pandemic, according to the study. The majority of respondents wore eye protection, masks, protective coverings and gloves during dental procedures. A second study in the joint research examined employment rates of dental hygienists, finding that 8% of dental hygienists had left the workforce since the onset of the pandemic. Of this

group, nearly 60% left the workforce voluntarily, citing reasons such as overall concerns around the pandemic, safety concerns and child care issues. According to the authors, COVID-19 has led to a reduction in the dental hygienist workforce that is likely to persist until the pandemic passes. Learn more about these studies in the Journal of Dental Hygiene.

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Microbes on Toothbrush Match Microbes Inside Mouth After studying microbial communities living on bristles from used toothbrushes, Northwestern University researchers found those communities matched microbes commonly found inside the mouth and on skin. This was true no matter where the toothbrushes had been stored, including shielded behind a closed medicine cabinet door or out in the open on the edge of a sink.

The study was published Feb. 1 in the journal Microbiome. The study’s senior author, Erica Hartmann, PhD, was inspired to conduct the research after hearing concerns that flushing a toilet might generate a cloud of aerosol particles. She and her team affectionately called their study “Operation Pottymouth.” Dr. Hartmann is an assistant professor of environmental

Stress-Related Dental Conditions Continue To Increase Stress-Related Dental Conditions Continue To Increase More than 70% of dentists surveyed by the American Dental Association (ADA) More Health Policy are surveyed seeing anbyincrease of patients teeth than 70%Institute of dentists the American Dentalexperiencing Association (ADA) grinding clenching, conditions often associated withexperiencing stress. This isteeth an increase Healthand Policy Institute are seeing an increase of patients grinding from ADA data released in the fallassociated that showed under dentistsfrom hadADA and clenching, conditions often withjust stress. This60% is an of increase seen anreleased increaseinamong patients.just under 60% of dentists had seen an increase data the falltheir that showed “Our polling has served as a barometer for pandemic stress affecting patients among their patients. and communities through eyes of dentists,” said Marko Vujicic, patients PhD, chief “Our pollingseen has served asthe a barometer for pandemic stress affecting and economist and seen vice president the ADA Healthsaid Policy Institute. “The increase communities through theofeyes of dentists,” Marko Vujicic, PhD, chief over time suggests stress-related have become substantially more over economist and vice president ofconditions the ADA Health Policy Institute. “The increase prevalent since the onset of COVID-19.” time suggests stress-related conditions have become substantially more prevalent since Theonset survey also found a little more than 60% of dentists saw an increase in the of COVID-19.” other stress-related dental including chipped andsaw cracked teeth and The survey also foundconditions a little more than 60% of dentists an increase in other temporomandibular disorderincluding (TMD) symptoms such as headaches stress-related dentaljoint conditions chipped and cracked teeth andand jawtemporomandibular pain. joint disorder (TMD) symptoms such as headaches and jaw pain. Despite speculation mask wearing wearingmay may Despite speculationfrom fromrecent recentnews newsreports reports that that frequent mask impact dental health found no no meaningful meaningfulchange impact dental healthand andcause cause“mask “maskmouth,” mouth,” the the survey survey found change the prevalence reported for conditions as badand breath and dry in the inprevalence reported for conditions such as such bad breath dry mouth compared mouth compared to pre-pandemic. to pre-pandemic. “As seeing stress-related stress-relateddental dentalconditions “Asthe thepandemic pandemiccontinues, continues, dentists dentists are seeing conditions andsaid more,” said Araujo, DDS, MS, PhD, ADA chief science officer. “It’s more andmore more,” Marcelo Marcelo Araujo, DDS, MS, for PhD, ADA to maintain their dental health, including seeing more important than ever people chief officer. “It’s more important thescience dentist regularly to address any issues that could have long-term impact.” than ever formore people to maintain their Learn about the work of the ADA Health Policy Institute. dental health, including seeing the dentist regularly to address any issues that could have long-term impact.” Learn more about the work of the ADA Health Policy Institute.

engineering at Northwestern’s McCormick School of Engineering. To obtain toothbrushes for the study, Dr. Hartmann’s team launched the Toothbrush Microbiome Project, which asked people to mail in their used toothbrushes along with corresponding metadata. The team then extracted DNA from the bristles to examine the microbial communities found there. They compared these communities to those outlined by the Human Microbiome Project, a National Institute of Health initiative that identified and catalogued microbial flora from different areas of the human body. The team found that the microbes on toothbrushes have a lot in common with the mouth and skin and very little in common with the human gut. During the research, the team examined how many different types of microbes lived on the toothbrushes. They found people with better oral hygiene, who regularly flossed and used mouthwash, had toothbrushes with less diverse microbial communities. The researchers also found that microbes from toothbrushes of people with better oral hygiene had slightly more antimicrobial-resistance genes. Dr. Hartmann said microbes with these genes did not match the human body and were likely from air or dust in the bathroom. Read more of this study in Microbiome (2021); doi. org/10.1186/s40168-020-00983-x. M AY 2 0 2 1

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Oral and Maxillofacial Imaging: Evolving Technologies and Paradigm Shifts Sanjay M. Mallya, BDS, MDS, PhD GUEST EDITOR Sanjay M. Mallya, BDS, MDS, PhD, is an associate professor and the chair of oral and maxillofacial radiology at the University of California, Los Angeles, School of Dentistry. He has authored numerous scientific manuscripts and book chapters on oral radiology, periodontology, endodontology and implantology. He is the editor of “White and Pharoah’s Oral Radiology” and is a past president of the American Academy of Oral and Maxillofacial Radiology. Dr. Mallya is a diplomate of the American Board of Oral and Maxillofacial Radiology and serves on the board of the Intersocietal Accreditation Commission. Conflict of Interest Disclosure: None reported.

he first digital sensor for intraoral imaging was introduced in 1989.1 Over the last 32 years, digital imaging has become the predominant technology used for intraoral imaging (~86%) and panoramic imaging (~82%) in the United States.2 Currently, dentists have a vast selection of digital imaging systems available from several vendors that include options for intraoral, panoramic and cephalometric imaging. These systems can be broadly divided into two technologies: complementary metal oxide semiconductor (CMOS)-based sensors and photostimulable phosphors (PSP).3 The image quality achievable with these digital receptors varies with the specific vendor product used4 — and this should be an important consideration for dentists seeking a digital imaging system for their practice. Equally important, dentists who purchase digital systems must ensure that the system is functioning as expected, with no deterioration of image quality over time. Contributors to the image quality include the X-ray source, the selected hardware components (sensor or PSP plate and reader), the software used to display and adjust the image appearance and the specifications of the computer monitor used to present the image to the dental team. Additionally, the ambient light conditions of the viewing environment may also impact image perception, adding another factor for consideration.

Recognizing that dental practices need straightforward guidance and direction to navigate through these factors, the ADA Standards Committee on Dental Informatics (SCDI) drafted and approved the ANSI/ADA Standard No. 1094 for Quality Assurance for Digital Intraoral Radiographic Systems.5 This document, the first of a series of documents addressing digital image quality control, outlines methods that the dental team can use to periodically confirm continued and expected performance of digital intraoral radiographic systems. The article by Dr. Peter Mah, Dr. Allison Buchanan and Dr. (Col) Teresa E. Reeves provides the first introduction to this standard. The information in this article discusses parameters of image quality and processes of digital image quality assurance and aims to make the reader an educated consumer and skillful user of digital imaging. Digital imaging technology, in particular CMOS-based imaging, allows us to make diagnostically adequate images with lower radiation than used for X-ray film. It is estimated that 382 million intraoral radiologic examinations are performed annually in the U.S.2 Approximately 20% of these examinations are performed on children, a group known to be more sensitive to radiation-induced cancer. The scope of imaging in dentistry has also expanded, driven by the availability of in-office cone beam computed tomography (CBCT) imaging. An estimated 5.2 million M AY 2 0 2 1

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CBCT examinations are done in the U.S., with approximately 28% of these examinations performed on children.2 The increasing use of computed tomography (CT) in health care, including dentistry, raised concerns for indiscriminate and unnecessary radiation exposure.6,7 This prompted responses from the profession leading to guidance for safety in imaging and establishing dose reference levels and from the vendors who incorporated dose reduction methods such as automatic exposure control in CT imaging. The article on safe and effective use of imaging emphasizes appropriate selection of patients for imaging as an essential step in radiation safety. The article informs the reader on the nature of diagnostic radiation’s effects and magnitude and, importantly, approaches to convey this information to patients in lay language. The availability of in-office CT imaging has markedly expanded the scope of imaging in dentistry. CT allows us to better view anatomy free of superimposition and distortion. CT data is combined with

other sources of digital information, such as optical scans, to fabricate surgical guides for implant planning. Importantly, the application of limited field of view (FOV) CBCT has markedly enhanced our ability to diagnose and manage diseases of the pulp and periapical tissues.8,9 To facilitate the effective use of CBCT imaging in dentistry, the American Association of Endodontists (AAE) and the American Academy of Oral and Maxillofacial Radiology (AAOMR) have developed guidelines that help clinicians identify those situations where CBCT imaging is likely to provide beneficial information.10 The article by Dr. Rumpa Ganguly and Dr. Mike Sabeti addresses the recommendations via a casebased presentation of clinical situations and the anticipated value of CBCT imaging. Readers of this article should identify that appropriate patient selection maximizes diagnostic yield and eliminates indiscriminate radiation exposure, underscoring that eventual implementation of effective and safe use of this technology lies in the hands of the end user. n

RE F E RE N C E S 1. Mouyen F, Benz C, Sonnabend E, Lodter JP. Presentation and physical evaluation of RadioVisioGraphy. Oral Surg Oral Med Oral Pathol 1989 Aug;68(2):238–42. doi: 10.1016/0030-4220(89)90200-4. 2. Hilohi MC, Eicholtz G, Eckerd J, Spelic DC. Tabulation and graphical summary of the 2014–2015 dental survey; 2019. 3. Mol A. Digital imaging. In: Mallya SM, Lam EW, eds. White and Pharoah’s Oral Radiology: Principles and Practice. 8th ed. St. Louis: Elsevier; 2018:40–60. 4. Udupa H, Mah P, Dove SB, McDavid WD. Evaluation of image quality parameters of representative intraoral digital radiographic systems. Oral Surg Oral Med Oral Pathol Oral Radiol 2013 Dec;116(6):774–83. doi: 10.1016/j. oooo.2013.08.019. 5. American National Standard/American Dental Association Standard 1094. Quality assurance for digital intraoral radiographic systems; 2020. 6. Brenner DJ, Hall EJ. Computed tomography — an increasing source of radiation exposure. N Engl J Med 2007 Nov 29;357(22):2277–84. doi: 10.1056/NEJMra072149. 7. Bogdanich W, McGinty JC. Radiation worries for children in dentists’ chairs. The New York Times Nov. 22, 2010. 8. Roda RS. Can use of cone beam computed tomography have an effect on endodontic treatment? J Calif Dent Assoc 2018 Apr;46(4):237–46. 9. Bakland LK. Evolving aspects of endodontic treatment. J Calif Dent Assoc 2018 Apr;46(4):221–25. 10. Fayad MI, Nair M, Levin MD, et al. AAE and AAOMR Joint Position Statement: Use of Cone Beam Computed Tomography in Endodontics 2015 Update. Oral Surg Oral Med Oral Pathol Oral Radiol 2015 Oct;120(4):508–12. doi: 10.1016/j.oooo.2015.07.033. Epub 2015 Aug 3.

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Applying the New ADA Quality Assurance Standard to Digital Intraoral Radiographic Systems Peter Mah, DMD, MS; Allison Buchanan, DMD, MS; and Teresa E. Reeves, DDS, JD, Col, USAF, DC

abstract This article is intended to describe the appropriate quality assurance (QA) methods for digital intraoral radiographic systems in accordance with ANSI/ADA Standard 1094. This article goes step by step through the digital imaging chain (the intraoral X-ray generator, the image receptor and acquisition software and the image display device), so the reader can achieve a complete understanding of what is required to successfully implement a comprehensive QA protocol within their own practice.

AUTHORS Peter Mah, DMD, MS, is the president of Dental Imaging Consultants LLC in San Antonio and is a consultant for the Air Force Medical Readiness Agency, San Antonio. He has served as a subject matter expert for the ADA Council on Dental Practice’s Ad Hoc Advisory Committee for Quality Assurance Inspection of Dental Radiographic Equipment and is a member of several working groups for the ADA Standards Committee on Dental Informatics including Working Group 12.1 on Digital Imaging, which is responsible for ANSI/ ADA Standard 1094. Dr. Mah is a diplomate

of the American Board of Oral and Maxillofacial Radiology and has published numerous manuscripts on dental radiographic imaging. Conflict of Interest Disclosure: Dr. Mah is the president of Dental Imaging Consultants LLC, which holds a patent for the Digital Dental Quality Assurance (DDQA) phantom and is an authorized distributor for RaySafe Unfors products.

Allison Buchanan, DMD, MS, is professor of radiology in the department of oral biology and diagnostic sciences at the Dental College of Georgia at Augusta University in Augusta, Georgia. She is the radiology consultant to the ADA Council on Dental Practice. Dr. Buchanan is a diplomate of the American Board of Oral and Maxillofacial Radiology and has published several studies in the area of quality assurance relating to digital imaging in dentistry. Conflict of Interest Disclosure: None reported.

Teresa E. Reeves, DDS, JD, Col, USAF, DC, is an associate professor of oral and maxillofacial radiology at the United States Air Force Postgraduate Dental School. She is currently serving at the David Grant Medical Center, Travis AFB, Calif., where she is also Air Force Military Radiology Consultant to the Surgeon General. Dr. Reeves is a diplomate of the American Board of Oral and Maxillofacial Radiology and has published studies in the area of quality assurance relating to digital imaging in dentistry. Conflict of Interest Disclosure: None reported. The views expressed are those of the authors and do not reflect the official views or policy of the Department of Defense or its components.

uality assurance (QA) is defined as the planned and systematic activities necessary to provide adequate confidence that a product or service will meet the given requirements.1 The need for QA with digital intraoral radiography was identified as early as 2003 in the National Council on Radiation Protection and Measurements (NCRP) Report 145, which stated in section 3.4.3.3 DigitalImaging Systems, “Procedures for evaluating the performance of digitalimaging systems are quite different from those used with film or screen-film image receptors. By using suitably designed phantoms and software, image quality aspects such as resolution, contrast, signal-to-noise ratio and contrast-tonoise ratio may be measured directly. However, the required standards, apparatus and software for dental systems do not currently exist. These limitations M AY 2 0 2 1

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are important factors when considering the purchase of digital-imaging systems.”2 As a result, the updated NCRP Report 177, Radiation Protection in Dentistry and Oral & Maxillofacial Imaging, includes instruction on intraoral digital imaging and quality control.2,3 Likewise, the American Dental Association (ADA) recognized the void in quality assurance for digital intraoral imaging and published Technical Report No. 1094 (TR 1094), Quality Assurance for Digital Intra-Oral Radiographic Systems, on May 31, 2017.4 And, in keeping with this pursuit to improve digital imaging QA in dentistry, the ADA Standards Council on Dental Informatics (SCDI) updated Technical Report 1094 to Standard 1094 in February 2020.5 A standard is the legal duty of a professional to exercise the level of care, diligence and skill prescribed in the standard, which now applies to ANSI/ ADA Standard 1094. This is different from guidelines, practice policies, recommendations and position statements in which strict adherence is not mandatory and, therefore, leaves room for professional discretion. Statutes are similar to standards in that they require compliance; yet, they differ in that they are not nationwide. Statutes apply only to the state in which they are passed. In cases where there may be conflict between an ADA standard and the state statute, the user would be mandated to comply with the stricter requirement. A few states have implemented some aspects of QA requirements for digital intraoral radiographic systems by statute whereas most other states have only protocols for film-based intraoral imaging.6–9 However, the methods to evaluate these are not clear and there are no acceptance or rejection criteria.9 For example, one state uses a maximum entrance skin dose as a method of image 292 M AY

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quality and prevention of overexposure of the patient.10 Other states rely on a mail-in QA program whereby one X-ray unit combination of an X-ray generator and image receptor is evaluated and assumed to be representative of all X-ray generator and image receptor combinations in the dental facility. Moreover, there are some states where the dental radiology statutes have not been updated since the 1980s prior to the widespread influx of digital intraoral radiography systems. Therefore, it

It was both necessary and prudent for the ADA to introduce a national quality assurance program for digital intraoral radiographic systems.

was both necessary and prudent for the ADA to introduce a national quality assurance program for digital intraoral radiographic systems. The purpose of this article is twofold. First, it serves to familiarize the reader with the new ANSI/ ADA standard 1094 (herein after referred to simply as Standard 1094). Second, it describes how to implement an effective QA program for digital intraoral radiographic systems in accordance with this new standard such that all X-ray generator and digital image receptors are evaluated. The methods described in this article will help clinicians generate and maintain image quality when using digital intraoral systems in their practices.

Introduction to Standard 1094: Quality Assurance for Digital Intraoral Radiographic Systems

Standard 1094 presents digital intraoral radiographic systems as a digital imaging chain consisting of interdependent components (the image display device, the intraoral X-ray generator and the image receptor and acquisition software) where a disruption in any one of the components may lead to a degradation in radiographic image quality. The components of the digital imaging chain often consist of equipment and software from different manufacturers, and each of these components affects the final displayed image. Therefore, it is necessary to implement a QA program to evaluate each component separately and then together as a single cohesive unit. With each of the three components in the imaging chain, there is a quality assurance acceptance test with specified requirements to ensure that the particular component performs as intended when delivered. Likewise, there are specified frequencies at which quality assurance tests are performed to ensure that the particular component continues to operate as intended. The first component in the digital imaging chain is the image display device and should be evaluated by displaying a standard digital image test pattern on the display screen. An example of such a test pattern is shown in FIGURE 1 . Details on how to use a standard digital image test pattern to calibrate the display device are provided in the section on implementation of the QA program. The second part of the digital imaging chain is the radiographic unit (i.e., the X-ray generator). To evaluate the X-ray generator performance, the following should be measured: radiation output in milliroentgen (mR) or milliGray (mGy), the peak kilovoltage (kVp),

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the exposure time in seconds and the half-value layer (HVL) in terms of thickness of aluminum. Additionally, tube head stability and collimation of the X-ray beam should be evaluated as part of the initial acceptance testing. The third component in the digital imaging chain is the digital image receptor and acquisition software. Standard 1094 states that the image receptor must be evaluated for signs of physical damage and that image quality must be assessed using a suitable radiographic phantom. The suitability of the acquisition software and associated system drivers should also be assessed.

Implementing the QA Program for Digital Intraoral Radiographic Systems The Image Display Device

Most modern commercial off-theshelf monitors with 1920 x 1080 display format are acceptable for viewing intraoral radiographs.11–13 There is no need to purchase expensive medical-grade monitors capable of displaying 12-bit grayscale images that meet DICOM Part 14 grayscale display function (GSDF) requirements. Because most dental radiographic systems display their radiographic images in 8 bits with 256 shades of gray, there is little to no benefit of using medical-grade monitors. Further, most publications suggesting that DICOM Part 14 GSDF calibration is required for dental viewing monitors have been from comparisons to the medical radiology viewing rooms where viewing conditions can be rigidly controlled and maintained, but this is not practical nor possible in a dental treatment room (DTR). DTRs require lighting conditions suitable for other dental tasks. The clinical viewing display in the DTR is used only for short bursts to visualize radiographs as part of a wider clinical assessment of oral health, therefore, it is

FIGURE 1. Society for Motion Picture and Television Engineers (SMPTE) Medical Diagnostic Imaging Test Pattern.

not practical for a DTR display to match the ideal medical-grade radiology monitors, calibration and viewing environments. Instead, the image display device can be evaluated by displaying a standard digital image test pattern.15 An example of such pattern is the Society for Motion Picture and Television Engineers (SMPTE) Medical Diagnostic Imaging Test Pattern and is available as freeware (FIGURE 1 ). Additionally, a vendor may provide a similar test pattern within the dental display software (FIGURE 2 ). This QA test protocol for the image display device shall be performed monthly and can be made in just a few minutes by the dentist, dental hygienist or dental auxiliary.4,5 Proper adjustment of the image display device should be performed under proper viewing conditions (see below). The SMPTE test pattern image should be

inspected for the absence of artifacts such as bleeding of bright display areas into dark areas or blurring of spatial resolution patterns.14,15 Additionally, appropriate dynamic range can be confirmed by ensuring that both the 5% and 95% inner squares are distinct from their respective adjacent 0% and 100% outer squares.4,5 The contrast and brightness settings of the monitor should be adjusted until all the gray levels are visible and delineation between the 5% and 0% and the 95% and 100% squares is achieved.15 The viewing environment, i.e., the level of ambient lighting, may affect the perceptibility of contrast differences in the digital radiograph.12,16–18 In fact, the brighter the background lighting, the higher the screen luminance necessary for perception of grayscale changes.18 Thus, the optimal viewing conditions are M AY 2 0 2 1

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FIGURE 2 . Software vendor monitor test pattern supplied with the dental display software.

monitors, and the loss in ability to visualize the grayscale is due to the decreased luminance that occurs.21,22 Therefore, the use of personal color photos as screen savers is discouraged because this will cause automatic optimization of the monitor to display colors and therefore will reduce the ability of the monitor to properly display grayscale values from dental radiographs. FIGURE 3 . Beam indicating device placed over

sensor portion of a radiation meter to record intraoral X-ray generator performance.

a quiet, darkened room.5 Additionally, the majority of the light from the display device should be from the digital image itself, therefore, use of a black background when viewing radiographs is appropriate.4 Dimmed ambient lighting is the optimum environment for image interpretation; however, obscuring or hooding of the image display device can reduce the ambient lighting by an average of 70% and can be used if there is too much ambient lighting in the dental viewing environment.12,19 Most image display devices are very stable over time; however, optimizing the image display for tasks other than radiographic interpretation may affect diagnostic performance.5 When LCD monitors are optimized for color display, the luminance of the display monitor decreases making it more difficult to discriminate grayscale differences.20,21 Grayscale display monitors are operated at a higher luminance than color display 294 M AY

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Intraoral X-Ray Generator

There can be confusion about the role of the state radiation inspector who inspects the radiographic equipment. These inspections are intended as safety checks to ensure that the radiographic equipment is functioning properly and, therefore, by itself does not constitute a QA program. In accordance with Standard 1094 and NCRP report 177, all X-ray generators shall be evaluated by a qualified expert prior to initial use.3–5 This initial evaluation can be carried out by the equipment installer, a medical physicist or a stateapproved radiation inspector and should be documented as part of the QA record for the device. Additionally, Standard 1094 recommends periodic constancy testing (i.e., measuring X-ray output) annually, unless there is a repair or other requirement to necessitate a shorter interval.4,5 Periodic constancy testing is a simple method to assess X-ray tube output and can be accomplished easily with the purchase of a modern electronic X-ray measuring device, sometimes referred to as a dosimeter, and additional training

for the dental staff.4,5 With the use of modern electronic X-ray measurement devices, the required QA tests may be completed in 10 to 15 minutes. The detector portion of the electronic X-ray meter is placed at the end of the beam indicating device (BID) and the exposure parameters utilized for the adult molar bitewing radiograph are used. These electronic X-ray meters are more than just dosimeters. With a single radiographic exposure, they provide radiation output in mR or mGy, the kVp, the exposure time in seconds, the HVL in terms of thickness of aluminum and the dose rate and number of pulses. FIGURE 3 shows an example of an electronic radiation meter measuring intraoral X-ray generator performance. Alternatively, the dental facility may retain the services of an X-ray vendor, dental X-ray equipment repair service provider, state licensed dental X-ray inspection provider or medical physicist. The periodic constancy testing performed by the dental facility is independent of the state-mandated tests that state inspectors may perform on the intraoral radiographic unit. The statemandated inspections are an outside validation for the performance of the X-ray generating equipment, whereas periodic constancy testing of the X-ray output is part of the QA program included in Standard 1094. The required QA checks of the X-ray unit are specified in their respective state statutes for dental radiography. A quick reference to each of the state’s applicable radiation regulations for dental imaging can be found at aaomr. org/radiation-regulations. Information for the state of California is also provided in the California Dental Association resource Radiation Safety in Dental Practice.8 The state-mandated inspections usually consist of evaluating the X-ray generator only and, in some states, recording the entrance skin

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exposure or air kerma value. Most states do not get involved with image quality.

Intraoral Image Receptor (Including Acquisition Software)

Intraoral digital image receptors should be evaluated initially (i.e., acceptance testing) and at periodic intervals. Two recent publications identified issues with new, unused intraoral image receptors.1,23 These issues included artifacts, delamination (uncoupling of scintillator), nonuniformity (light and dark areas, dark banding) and latent images.1,23 FIGURES 4 and 5 provide examples of delamination and nonuniformity. The first step in the evaluation of a digital image receptor should be a physical examination of the image receptor. Owing to differences in the construction and requirements for the physical inspection of direct capture and indirect capture receptors, these are divided into two sections.

FIGURE 4 . Examples of delamination with digital image receptors.

Direct Capture Intraoral Image Receptor (CCD and CMOS) — Physical Inspection

The direct capture image receptor should be continually checked for integrity to make sure that the product is intact, not split or missing part of the protective plastic casing, the sensor wire is not frayed, broken, kinked or damaged and the computer connector is intact. Significant bitemarks on the active sensor side of the image receptor may be an indication of internal damage.

Indirect Capture Intraoral Image Receptor (PSP) — Physical Inspection

Photo-stimulable phosphor plate (PSP) inspection involves looking for obvious scratches, bitemarks and physical damage such as bent plates and separation or delamination of the phosphor layers from the base. Examples of damaged

FIGURE 5 . Examples of nonuniformity with digital image receptors.

PSP plates are shown in FIGURE 6 . Additionally, with PSP digital imaging systems, the scanner is another part of the imaging chain that must be inspected. NCRP Report 177 recommends regular cleaning of the PSP plate and scanner transport assembly as well as performing radiographic phantom tests on PSP plates every 40 exposures per plate.3

Image Optimization and Radiation Dose Control

The maximum diagnostic yield of the image receptor is defined as the highest spatial and contrast resolutions

achieved while maintaining visibility of the full dynamic range. The optimal exposure is defined as the exposure parameters that produce the maximum diagnostic yield for the image receptor at the lowest radiation exposure.1,24–26 The radiographs produced at the lowest and highest radiation exposures while still maintaining the dynamic range represent the exposure range or latitude of the image receptor. The latitude of the image receptor may vary slightly depending upon the combination of components in the imaging chain such as the intraoral X-ray unit (i.e., generator), the image M AY 2 0 2 1

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acquisition software and the image display device. Even with the same brand, model and vintage of digital intraoral image receptor type, there are measurable differences in image quality using the same radiographic exposure parameters with the same X-ray generator.25,27

Quality Assurance Phantoms

FIGURE 6 . Examples of damaged PSP plates with a photograph of the PSP plate and resulting

radiographic image.

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The method to determine the optimal exposure with a radiographic phantom designed for digital intraoral radiographic systems is explained in Standard 1094, ADA TR 1094, Mah et al., Udupa et al., Walker et al., Reeves et al. and Buchanan et al.1,4,5,24–26,28 This method works for all combinations of intraoral X-ray generators, short- and long-cone round and rectangular collimators (i.e., BIDs), image receptors (direct and indirect capture), viewing monitors and acquisition software. To determine the optimal exposure, the radiographic phantom should have repeatable projection geometry and the ability to measure the dynamic range across the entire range necessary for dental imaging (no attenuation to full attenuation of the X-ray beam), spatial resolution, contrast perceptibility and latitude.1,3–5,14 Using a contrast detail phantom alone does not allow one to evaluate the spatial resolution, dynamic range or latitude of the intraoral radiographic system. Likewise, the use of a spatial resolution pattern alone does not allow the user to evaluate the contrast perceptibility, the dynamic range or the latitude of the intraoral radiographic system. It should also be noted that the use of an aluminum step wedge alone does not allow one to identify the optimal exposure for the image receptor (FIGURE 7 ). While gross under- and overexposure is apparent in FIGURE 7 , there is no way to identify the optimum exposure due to the lack of measurement of spatial and contrast

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resolutions and the inability to determine full dynamic range due to lack of air (no attenuation) and lead (full attenuation) steps. It is critical that the contrast perceptibility, spatial resolution and dynamic range of the intraoral radiographic system be evaluated simultaneously within the same radiographic image. Additionally, the projection geometry must simulate intraoral projection geometry to prevent erroneous errors owing to properties of the inverse square law.3–5 The reader is cautioned to ensure that the QA phantom they acquire for their dental facility meets all the criteria mentioned above as specified in Standard 1094.

Software

It is important that there is minimal image processing from software when determining the optimal exposure for the image receptor.1,26,29,30 One must turn off the enhancement options within the software to produce a “raw” image. In reality, this creates a minimally processed image rather than an actual raw image because some of the software enhancements are programmed by the manufacturer or installed by the digital system installer without the end-user having control over them.30 Changes in software settings that can be made to produce a minimally processed image include setting the gamma value to 1 (a gamma value of 1 is equivalent to no gamma correction), turning off sharpening and smoothening filters and histogram adjustments.1 Once the optimal exposure has been determined, subsequent images can be acquired for comparison to ensure that any software filter that is applied does not result in loss of data. This allows one to assess the effects of software manipulation on diagnostic quality. A comprehensive QA program should include appropriate evaluation of the effects of software on the diagnostic quality of the image.26 It should

FIGURE 7. Aluminum step wedge over an incrementally increasing exposure from 6.59mR to 527mR.

be stressed, however, that software changes, regardless of when in the imaging chain they are applied, should not be used in an attempt to compensate for an incorrectly exposed radiograph. Rather, one must start with a properly exposed radiograph (i.e., image optimization) in order to benefit from software adjustments.29

Discussion

As described in detail in this article, an effective QA program evaluates all portions of the imaging chain. The QA program should be implemented within the facility itself, as each component of the imaging chain (display device, X-ray generator and image receptor and software) can affect the ultimate image quality. Therefore, a request by the state to provide a radiographic image produced with one of the X-ray generator/image receptor combinations from the dental office is not an acceptable assessment of image quality. This one evaluation does not account for the different radiographic units (generators), different image receptors and accompanying software or the different display devices. A review of recommendations by the state dental associations as well as the varied inspection requirements for digital intraoral radiography, illustrate the lack of consensus on effective QA protocols for digital intraoral radiographic systems.6–10

A literature search on QA for digital intraoral radiographic systems seems just as varied with recommendations of measuring noise, signal to noise ratios, contrast to noise ratio, homogeneity, uniformity and other tests.2,31,32 It is clear from these practices and the lack of consensus on effective QA protocols in dentistry that there is a need for a universal QA standard for digital intraoral radiographic systems. With the introduction of Standard 1094, it is hoped that there will be a migration toward a practical and scientific approach to address this issue. “The American Dental Association (ADA) is an ANSI accredited standards developing organization. ADA standards have been approved as American National Standards by ANSI and thus they are designated as ANSI/ ADA Standards. Further, ANSI is the U.S. member to ISO. The U.S. TAG for ISO/TC 106 determines the U.S. vote on all dental standards and provides this input to ANSI for ISO/TC 106.”33 As such, the ADA is the sole standards group for dentistry in the U.S. and failure to adhere to an ADA standard would be deemed as failing to meet equipment performance standard for intraoral X-ray systems. Standard 1094 will serve as the national standard for all dental facilities and should assist in consolidating an effective QA program nationwide. M AY 2 0 2 1

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Although the ADA is the dental standards organization in the U.S., not all publications from the ADA are standards and one must be able to differentiate and recognize the difference in compliance requirements of these ADA publications.34 There are many special interest groups in addition to the ADA that propagate guidelines, practice policies, recommendations and position statements. However, strict adherence to these, unlike a standard, is not mandatory. Examples of agencies that publish guidelines, practice policies, recommendations and position statements are the National Council on Radiation Protection and Measurements (NCRP), the American Association of Physicists in Medicine (AAPM), the American Academy of Oral and Maxillofacial Radiology (AAOMR), state and local dental associations, Image Gently, Image Wisely and the ADA. Some states do adopt the guidelines issued by these special interest groups. An example of this is adoption of the radiation safety practices recommended by the NCRP by some states, and as such strict adherence would be required for those in that state. Statutes are usually passed by an individual state to mandate those users of that technology, equipment or practice to comply with use terms as per state legislation. As mentioned previously, in cases where there is overlap or conflict between an ADA standard and the state statute, the stricter requirement prevails. State statutes are mandatory in that state only and failure to adhere to a state statute may result in warnings, fines, enforcement actions or a combination of these. As a standard is the legal duty to provide the level of care prescribed in the standard, the approval of Standard 1094 should help define QA for digital intraoral imaging on a national scale. Therefore, dental providers and personnel must understand QA in digital intraoral 298 M AY

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radiographic systems as well as accept responsibility for QA of the components used in the trusted care of their patients.

Conclusion

QA is critically important to maintaining high-quality diagnostic radiographs and in keeping with the radiation hygiene principle of ALARA. Throughout the paper, there are examples to help clinicians recognize many of the problems encountered in digital intraoral radiography. We have provided images wherever possible to help the reader visualize and appreciate the concerns. This paper presents and supports the need for a universal QA program for digital intraoral radiography given the varied and sometimes conflicting recommendations for digital intraoral radiography QA processes. n Note: No financial support was received from any external source or vendor for this project. This research did not receive any specific grant from funding agencies in the public, commercial or nonprofit sectors. RE FE RE N CE S 1. Reeves TE, Lien W, Mah P. Quality assurance: Acceptance testing for digital dental intraoral sensors. Oral Surg Oral Med Oral Pathol Oral Radiol 2020 Apr;129(4):388–400. doi: 10.1016/j.oooo.2019.11.005. Epub 2019 Nov 14. 2. National Council on Radiation Protection and Measurements. Radiation protection in dentistry. NCRP Report 145 2003:1–201. 3. National Council on Radiation Protection and Measurements. Radiation protection in dentistry and oral and maxillofacial imaging. NCRP Report No 177. 2019:1–245. 4. American Dental Association. Technical Report No. 1094 Quality Assurance for Digital Intra-Oral Radiographic Systems. 2017. 5. American National Standard Institute/American Dental Association Standard No.1094 Quality assurance for digital intraoral radiographic systems. (ANSI/ADA Standard No. 1094). 2020. 6. North Carolina Division of Health Service Regulation Radiation Protection Section. Digital imaging tips for lower radiation doses and better image quality in dentistry. Radiology Compliance Branch. 2015. 7. Minnesota Department of Health. X-ray regulatory guide dental X-ray facilities. 2015. 8. California Dental Association. Radiation safety in dental

practice — a study guide. 2014:1–69. 9. Texas Department of State Health Services. Radiation control regulations for dental radiation machines Texas regulations for control of radiation. 2019;25 Texas Administrative Code 289.232. 10. North Carolina Division of Health Service Regulation Radiation Protection Section. Entrance skin exposure (ESE) facts — dental. Radiology Compliance Branch. 2015. 11. Hellen-Halme K, Nilsson M, Petersson A. Effect of monitors on approximal caries detection in digital radiographs — standard versus precalibrated DICOM part 14 displays: An in vitro study. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2009 May;107(5):716–20. doi: 10.1016/j.tripleo.2008.12.011. Epub 2009 Feb 6. 12. Hellen-Halme K, Lith A. Effect of ambient light level at the monitor surface on digital radiographic evaluation of approximal carious lesions: An in vitro study. Dentomaxillofac Radiol 2012 Mar;41(3):192–6. doi: 10.1259/dmfr/15422221. 13. Lima CAS, Freitas DQ, Ambrosano GMB, Haiter-Neto F, Oliveira ML. Influence of interpretation conditions on the subjective differentiation of radiographic contrast of images obtained with a digital intraoral system. Oral Surg Oral Med Oral Pathol Oral Radiol 2019 May;127(5):444– 450. doi: 10.1016/j.oooo.2019.01.003. Epub 2019 Jan 9. 14. American Association of Physicists in Medicine (AAPM). Acceptance testing and quality control of dental imaging equipment. 2016; AAPM Report No. 175:1–30. 15. Aldrich JE, Rutledge JD. Assessment of PACS display systems. J Digit Imaging 2005 Dec;18(4):287–95. doi: 10.1007/s10278-005-6974-7. 16. Wade C, Brennan PC. Assessment of monitor conditions for the display of radiological diagnostic images and ambient lighting. Br J Radiol 2004 Jun;77(918):465–71. doi: 10.1259/bjr/18928981. 17. Haak R, Wicht MJ, Hellmich M, Nowak G, Noack MJ. Influence of room lighting on grey-scale perception with a CRT-and a TFT monitor display. Dentomaxillofac Radiol 2002 May;31(3):193–7. doi: 10.1038/sj/ dmfr/4600668. 18. Flynn M. DICOM basics pertaining to displays society for imaging informatics in medicine. siimorg.org/page/ displays_chapter3, 2020. 19. Kutcher MJ, Kalathingal S, Ludlow JB, Abreu Jr. M, Platin E. The effect of lighting conditions on caries interpretation with a laptop computer in a clinical setting. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2006 Oct;102(4):537–43. doi: 10.1016/j.tripleo.2005.11.004. Epub 2006 Jun 19. 20. Dreyer K HD, Thrall J, Mehta A. PACS: A Guide to the Digital Revolution. 2nd ed. New York: Springer; 2005: 347–362. 21. Hirschorn DS, Krupinski EA, Flynn MJ. PACS displays: How to select the right display technology. J Am Coll Radiol 2014 Dec;11(12 Pt B):1270–6. doi: 10.1016/j. jacr.2014.09.016. Epub 2014 Dec 1. 22. Gray JE. Use of the SMPTE test pattern in picture archiving and communication systems. J Digit Imaging 1992 Feb;5(1):54–8. doi: 10.1007/BF03167824. 23. Buchanan A, Morales C, Looney S, Kalathingal S. Fish scale artefact on an intraoral imaging receptor. Dentomaxillofac Radiol 2017 Dec;46(8):20170224. doi:

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10.1259/dmfr.20170224. Epub 2017 Oct 20. 24. Walker TF, Mah P, Dove SB, McDavid WD. Digital intraoral radiographic quality assurance and control in private practice. Gen Dent Sep–Oct 2014;62(5):22–9. 25. Udupa H, Mah P, Dove SB, McDavid WD. Evaluation of image quality parameters of representative intraoral digital radiographic systems. Oral Surg Oral Med Oral Pathol Oral Radiol 2013 Dec;116(6):774–83. doi: 10.1016/j. oooo.2013.08.019. 26. Buchanan A, Hancock R, Kalathingal S. The role of software in quality assurance for indirect digital intraoral imaging. Oral Surg Oral Med Oral Pathol Oral Radiol 2020 Sep;130(3):313–321. doi: 10.1016/j. oooo.2020.03.043. Epub 2020 May 17. 27. Olsson L, Nilsson M, Svenson B, Hellen-Halme K. The effect of anatomical noise on perception of low contrast in intraoral radiographs: An in vitro study. Dentomaxillofac Radiol 2016;45(4):20150402. doi: 10.1259/ dmfr.20150402. Epub 2016 Feb 19. 28. Mah P, McDavid WD, Dove SB. Quality assurance phantom for digital dental imaging. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2011 Nov;112(5):632–9.

doi: 10.1016/j.tripleo.2011.05.015. Epub 2011 Sep 8. 29. Mol A, Yoon DC. Guide to digital radiographic imaging. J Calif Dent Assoc 2015;43(9):503–11. 30. Buchanan A, Orta A, Kalathingal S. Postprocessing of all-zirconia restorations in digital dental radiographs: A quality assurance predicament. Oral Surg Oral Med Oral Pathol Oral Radiol 2019 Apr;127(4):330–338. doi: 10.1016/j.oooo.2018.12.013. Epub 2018 Dec 31. 31. Hellen-Halme K, Johansson C, Nilsson M. Comparison of the performance of intraoral X-ray sensors using objective image quality assessment. Oral Surg Oral Med Oral Pathol Oral Radiol 2016 May;121(5):e129–37. doi: 10.1016/j. oooo.2016.01.016. Epub 2016 Feb 13. 32. Greenall C, Drage N, Ager M. Quality assurance tests for digital radiography in general dental practice. Dent Update 2014 Mar;41(2):126–8, 131–4. doi: 10.12968/ denu.2014.41.2.126. 33. American Dental Association. Standards Committee on Dental Informatics (SCDI). www.ada.org/en/scienceresearch/dental-standards/standards-committee-on-dentalinformatics Accessed Dec. 16, 2020. 34. American Dental Association. Dental Standards. ADA/

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radiation risk C D A J O U R N A L , V O L 4 9 , Nº 5

Effective and Safe Use of X-Rays: Understanding the Risks for Decision-Making Sanjay M. Mallya, BDS, MDS, PhD

abstract Background: X-radiation is part of the dentist’s diagnostic armamentarium and is used to make radiologic images for diagnosis and treatment planning. However, the hazards of X-radiation — in particular, its potential to induce cancer — have concerned health care providers and patients. Application of diagnostic imaging is based on the premise that the benefits will vastly outweigh the risks. Results: The first part of this article discusses increasing imaging effectiveness with proper patient selection — a critical and frequently overlooked step toward maximizing diagnostic benefit. The second part provides a basic understanding of the risks from diagnostic X-radiation, including typical doses from maxillofacial radiologic procedures and the magnitude of associated radiation-related risks. Practical applications: This article provides approaches for the dentist to communicate radiation risks to their patients in lay terms. It also highlights recent developments of importance to dental practice — developing changes to practices of gonadal and fetal shielding during diagnostic imaging. Key words: Evidence-based imaging, radiation risk, radiation safety

AUTHOR Sanjay M. Mallya, BDS, MDS, PhD, is an associate professor and the chair of oral and maxillofacial radiology at the University of California, Los Angeles, School of Dentistry. He has authored numerous scientific manuscripts and book chapters on oral radiology, periodontology, endodontology and implantology. He is the editor of “White and Pharoah’s Oral Radiology”

and is a past president of the American Academy of Oral and Maxillofacial Radiology. Dr. Mallya is a diplomate of the American Board of Oral and Maxillofacial Radiology and serves on the board for the Intersocietal Accreditation Commission. Conflict of Interest Disclosure: None reported.

-rays have sufficient energy to ionize biologic molecules and possibly cause damage that is manifested as disease. Nevertheless, despite its potentially hazardous effects, X-ray-based imaging continues to be an essential tool for diagnosis and treatment planning in health care, including dentistry. For example, asymptomatic patients are screened to detect incipient caries lesions using bitewing radiography. Alternatively, a patient with a periapical abscess may be imaged using intraoral periapical

imaging. In another clinical scenario, cone beam computed tomography (CBCT) may be prescribed to evaluate the relationship between an impacted mandibular third molar and the inferior alveolar canal. Although the specific diagnostic objective in each scenario is unique, the principles that guide the decision to make radiologic images are the same. The first principle addresses the effectiveness of imaging and is based on the tenet that radiologic examination will likely provide information relevant to diagnosis and treatment planning. M AY 2 0 2 1

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TABLE 1

Guidelines for Dentomaxillofacial Imaging Imaging guideline

Authoring organizations

Intraoral, panoramic and cephalometric imaging

American Dental Association and the Food and Drug Administration, U.S. Department of Health and Human Services1

Dental implantology

American Academy of Oral and Maxillofacial Radiology7

Dental implantology

International Congress on Oral Implantology4

Dental implantology

American College of Prosthodontics3

CBCT in orthodontics

American Academy of Oral and Maxillofacial Radiology2

CBCT imaging, periodontology and implantology

American Academy of Periodontology35

CBCT in endodontics

American Association of Endodontists and Academy of Oral and Maxillofacial Radiology5

CBCT imaging

SEDENTEXCT Consortium6

Guided by this principle, the dentist must design an appropriate radiologic examination to yield high diagnostic benefit. The second principle addresses the safety of the radiologic examination and ensures that radiation-associated risks will be negligible relative to the diagnostic benefit. To appropriately apply these principles in practice, dentists must understand the advantages and limitations of the imaging modalities used and the nature and magnitude of radiationassociated risks. When appropriately applied, dentists create a positive balance where the anticipated benefits vastly outweigh the estimated risks and thereby frame the logical basis for effective and safe use of X-rays in dentistry.

Effective Imaging

Radiologic imaging is one component of the comprehensive process of diagnosis and treatment planning. Prior to prescribing radiologic imaging, the clinician must first establish a provisional diagnosis based on the medical and dental history, clinical presentations, findings from the visual and physical examinations and other diagnostic tests. These findings should guide the clinician to develop distinct diagnostic objectives that will be addressed by imaging and to design the appropriate radiological examination to achieve these objectives. 302 M AY

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Effectiveness of imaging refers to the likelihood that radiologic examination will accomplish the objectives of imaging. In practice, the clinical team has an important role to maximize imaging efficacy in their individual clinic environments. This is accomplished by customizing radiologic examinations to maximize diagnostic yield in individual patients and optimizing the clinic’s imaging and interpretation procedures.

Customize Imaging To Maximize Diagnostic Yield

The first facet of imaging effectiveness is to custom design radiologic examinations to meet the diagnostic needs of individual patients. This requires familiarity with the performance efficacy of different imaging procedures. To facilitate application of data-driven imaging in practice, professional societies have developed guidelines and position statements that address selection of patients for intraoral, panoramic, cephalometric1 and CBCT imaging2–7 (TA BLE 1 ). These guidelines provide evidence-based recommendations for distinct diagnostic objectives. Application of patient-selection guidelines in practice will allow dentists to maximize the diagnostic yield, thereby enhancing imaging effectiveness. Imaging effectiveness, also termed efficacy, is expressed using the measures

sensitivity and specificity.8 Sensitivity refers to the ability of a diagnostic test to correctly identify presence of disease. Specificity refers to a diagnostic test’s ability to identify absence of disease. It is important to recognize that sensitivity and specificity are measures of a distinct diagnostic task. For example, 1B although both tasks address caries detection with bitewing imaging, the sensitivity and specificity for detection of noncavitated caries lesions on proximal surfaces of posterior teeth differs from the sensitivity and specificity of detection of cavitated caries lesions on proximal surfaces of posterior teeth. Note that sensitivity is a measure of how well your test can detect disease when it is present. This influences your selection of the imaging method you apply for disease detection — for example, in the case of proximal caries detection, we rely on bitewing radiographs and not panoramic radiographs. In practice, the chairside performance of the bitewing radiograph is reflected in its predictive value — the reliability of a positive (or negative) test result. The positive predictive value (PPV) is the fraction of positive tests that are truly positive. The negative predictive value (NPV) is the fraction of negative tests that are truly negative. Although sensitivity and specificity measure a diagnostic test’s performance, they are not of immediate relevance to clinical decision-making as described in BOX 1 . A practical example of appropriate application of imaging is illustrated with an example decision of how frequently to image an asymptomatic recall patient (BOX 1 ). The diagnostic objective of this screening radiograph is to detect caries before it becomes clinically apparent. In practice, how frequently should dentists apply this screening to their patients? To address this issue, the application

C D A J O U R N A L , V O L 4 9 , Nº 5

BOX 1

Appropriate Patient Selection To Maximize Diagnostic Yield

of bitewing imaging is simulated for two scenarios that vary in caries prevalence — 50% versus 5%. Both scenarios use bitewing radiography, so radiation-associated risks to patients are equivalent. The major difference between the two scenarios is reflected in their positive predictive value — in scenario one, a dentist scoring presence of caries would be correct 86% of the time. In stark contrast, this value drops sharply to 25% in scenario two and would result in increased misdiagnosis and potential unnecessary treatment. It may seem counterintuitive that using the same technology with the same interpretation criteria will yield different results when applied to different populations. However, this principle is the key element to maximizing diagnostic yield — application of the same diagnostic test in different patient populations yields different benefits. Thus, the benefit-torisk ratio in scenario one is substantially higher than in scenario two. This difference in the benefit-to-risk ratio is reflected in the recommended screening radiography schedules;1 in patients with high caries risk, the schedules are more frequent, every six to 18 months depending on risk. In contrast, for patients with no caries risk, where the benefits are lower, the recommended schedule is every 24 to 36 months.1 Note that by applying appropriate patient selection guidelines, dentists can make major changes in the effectiveness of their imaging results. A recent study in the Journal of the American Dental Association showed that less than 50% of dentists apply evidence-based imaging guidelines in their practices with resultant overprescription of imaging.9 The reasons for such practices are likely multiple and may derive from financial benefits, lack of

Designing effective screening for proximal caries with bitewing radiographs Bitewing radiographs are used to screen for proximal caries. The case scenarios will demonstrate the positive impact of applying imaging to an appropriate patient population and the ineffectiveness of imaging when applied inappropriately. Specific diagnostic task: Detect proximal caries in an adult patient with no clinical discoloration or cavitation in an adult patient. Diagnostic test: Bitewing radiography Performance parameters of test:a sensitivity = 36%, specificity = 94% Scenario 1: Disease prevalence = 50% CARIES PRESENT

CARIES ABSENT

Radiograph positive

PPV b = 86%

Radiograph negative

NPV b = 59%

100

CARIES PRESENT

CARIES ABSENT

108

PPV = 25%

1692

NPV = 93%

100

1800

Scenario 2: Disease prevalence = 5%

Radiograph positive Radiograph negative

Scenario 1

Scenario 2

Benefit

PPV = 86%

PPV = 25%

Radiation dose

5 µSv

ADA selection criteria:1 Applies the above benefit-to-risk ratios to design screening frequency for proximal caries. When the anticipated diagnostic yield is low, the screening is accordingly performed less frequently. • Increased caries risk (high diagnostic yield): Posterior bitewings every six to 18 months. • No caries risk (low diagnostic yield): Posterior bitewings every 24 to 36 months. ª Sensitivity and specificity data derived from Schwendicke et al.26 b PPV = positive predictive value; NPV = negative predictive value.

guidelines knowledge, easy availability of in-office CBCT imaging and misperceptions of medicolegal risk and underscore the need to better promote evidence-based imaging. The most recent report from the Nationwide Evaluation of X-ray Trends (NEXT) estimated almost 400 million intraoral radiographs and approximately 5.2 million CBCT examinations are done every year in the U.S.10 Efforts

to decrease unnecessary imaging will not only reduce radiation dose, but also impact dental treatment costs.

Make and Interpret Diagnostically Acceptable Images

The second facet of imaging effectiveness is making and interpreting diagnostically acceptable radiologic images. To this end, the dental team has four broad roles as summarized next. For M AY 2 0 2 1

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current practical relevance, the discussion is limited to digital imaging technologies. Know the technical capabilities of the imaging system: In-office imaging modalities used in dentistry include intraoral, panoramic, cephalometric and CBCT imaging. Dentists must be familiar with the basic technical specifications of the imaging systems used in their offices. This includes both the hardware and software components. Importantly, dentists must understand the advantages and limitations of different imaging approaches so they can design appropriate imaging examinations to meet specific diagnostic needs. Most vendors of digital intraoral sensors provide software to manipulate the display of the radiologic image — for example, brightness and contrast adjustments, image sharpness, etc. Understanding the appropriate application of such tools will allow the dentist to better use information for these images. Optimize exposure factors to make high-quality diagnostic images: An essential and critical step in maximizing imaging effectiveness is to optimize imaging protocols to make diagnostically acceptable images with optimal density, contrast and resolution that are adequate for the diagnostic task. For example, when a practice buys a new digital sensor, they should make phantom images to select the lowest exposure time to make diagnostic images and establish a technique-setting chart that is followed by all office staff. Each imaging system must be optimized to define exposure settings, which is the focus of a separate manuscript in this issue. Optimize the viewing environment: The image viewing display and room lighting conditions are practical factors that influence the quality of the image presented to the dentist for interpretation. 304 M AY

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The diagnostic assessments may be made on a display monitor, a laptop computer or a tablet. Standard test patterns are available to aid the dentist in adjusting display parameters to confirm that the required latitude and contrast are perceptible.11 Systematically interpret the image: The dentist’s ability to extract information from the image is central to achieving high effectiveness of imaging. This requires that dentists maintain and update their radiologic interpretive skills. This

The dentist’s ability to extract information from the image is central to achieving high effectiveness of imaging.

is especially important when adopting newer imaging technologies such as CBCT, where foundational knowledge in CT technology and 3D anatomy are necessary for interpretation. As needed, dentists should seek appropriate consultative specialty opinion to maximize the diagnostic information obtained from the radiologic examination. The use of teleradiology has facilitated easy access to this consultative service.

Safe Use of X-rays

Broadly, the phrase “safe use of X-rays” refers to approaches taken by the dental team take to minimize radiation dose to their patients, themselves and the public. This manuscript focuses on radiation-associated risks from dentomaxillofacial diagnostic imaging and

presents the dentist with data to better understand the magnitude of these risks.

What Are the Effects From X-radiation? Radiation effects can be categorized as stochastic effects and tissue reactions. Each category has different implications for radiation safety, and aspects relevant to dental practice are discussed below.

Stochastic Effects

Stochastic effects occur due to mutations consequent to misrepair of radiation-induced DNA damage. One stochastic outcome of radiation exposure is cancer resulting from mutations occurring in somatic cells. Another stochastic outcome is hereditary effects resulting from germ cell mutations following gonadal radiation exposure and manifested as disease in the exposed individual’s offspring. As discussed below, hereditary effects are not a concern from dental diagnostic imaging, and cancer induction is the only radiation-associated risk from dentomaxillofacial diagnostic imaging and the magnitude of these risks are low. Radiation-induced cancer has been scientifically established by animal studies as well as studies of several human populations that were exposed to radiation. The Life Span Study, which monitors radiation effects in atomic bomb survivors, has provided considerable information on radiation’s carcinogenic effects. Overall, these studies have shaped important concepts of relevance to radiation safety and protection.12 ■ Cancer induction has been demonstrated at doses above 100 mSv, and risk modeling demonstrates a linear dose response. However, the carcinogen effects of radiation are unclear at doses below 100 mSv — the dose range of all diagnostic radiologic procedures. Although radiation doses for

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BOX 2

Approaches To Minimize Radiation Dose to Patients Practice patient selection for imaging to maximize effectiveness Use technology that provides dose reduction

■

stochastic effects are considered cumulative, the relatively low magnitude of dental exposures would require thousands to tens of thousands of dental exposures to total 100 mSv. The current model for risk prediction at lower doses is based on linear extrapolation of higher-dose data. This model, the linear no-threshold (LNT) model, considers that there is no threshold dose for cancer induction and implies that even the smallest amount of X-radiation carries a risk for cancer induction. The no-threshold model guides current radiation protection practices.13 In the absence of scientific data to support or refute the LNT model, radiation protection agencies worldwide have adopted a prudent approach to low-dose risk estimation, and current protection efforts are based on the premise that there is no threshold dose for this adverse outcome. Opponents of the LNT model argue that the presence of repair mechanisms and adaptive responses contributes to lower risk at low doses than is predicted by the LNT model, with some groups arguing the presence of a threshold dose for cancer induction.14 These groups argue that a conservative approach could compromise application of diagnostic imaging and that the increased protection efforts add unnecessary costs. Nevertheless, current federal and state radiation protection regulations are based on the LNT model’s risk prediction, and this issue continues to be intensely debated. Certain organs and tissues demonstrate increased sensitivity to cancer induction by radiation.

o Constant potential or “DC” intraoral X-ray units provide an X-ray beam with less energy fluctuation and a higher mean energy. This decreases patient surface dose and allows more consistent production of X-rays with shorter exposure times, especially useful when using digital sensors o Compared with film, digital sensors for intraoral imaging need less radiation to create a radiologic image — dose is decreased by ~50% and an image is obtained instantaneously without chemical processing o Do not use D-speed film — it requires almost fourfold more radiation than used for digital sensors with no added diagnostic benefit Optimize exposure protocols for your imaging system Establish child and adult exposure settings considering patient size and anatomy Practice beam restriction o Rectangular collimation with intraoral radiography o Smallest field of view (FOV) that covers required anatomy for CBCT imaging Use thyroid collars when it does not obscure required anatomic details (see Box 3)

In the head and neck, these include the thyroid gland, salivary glands, red bone marrow and the brain. Minimizing dose to these sensitive organs during imaging will decrease radiation-associated risks. The acronym ALARA (as low as reasonably achievable) provides the guiding principle for dose reduction efforts. Approaches to dose reduction are listed in BOX 2 . ■ Children are more sensitive to radiation-induced cancer, emphasizing the need to specifically enhance risk reduction efforts in children. ■ Cancer is manifested years to decades following radiation exposure. Thus, an exposed child has a higher likelihood of manifesting radiation-induced cancer during their lifetime in contrast with an elderly exposed individual. This emphasizes the need to specifically enhance riskreduction efforts in children. Radiation-induced thyroid cancer is of particular relevance to dentomaxillofacial imaging. The thyroid gland is sensitive to cancer induction by radiation, especially before age 20.15 Cancer risks decrease sharply when exposed at ages older

than 20 years, and there have been no demonstrated risks in adults exposed at an age older than 40 years. The thyroid gland is exposed either directly by the primary beam or by scatter radiation from adjacent exposed areas. Thyroid shields can minimize the dose and should be used when they will not obscure necessary anatomic details. The NCRP Report No. 17716 recommends that “Thyroid shielding shall be provided for patients when it will not interfere with the examination.” This recommendation is also the position of the American Thyroid Association17 and the American Dental Association.1 BOX 3 summarizes the scientific data on radiation-induced thyroid cancer that supports use of thyroid shielding during dentomaxillofacial imaging. Heritable effects result from germ cell mutations that may manifest as disease in the exposed individual’s offspring. Although demonstrated in animal studies, there is no evidence of radiationinduced heritable disease in humans.18 Thus, heritable risks are practically nonexistent with diagnostic imaging. However, the U.S. federal regulations and several U.S. state radiation regulations require use of gonadal shielding when imaging patients. Current California state regulations require that “Each patient M AY 2 0 2 1

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BOX 3

Preventing Thyroid Cancer: Scientific Rationale To Continue Using Thyroid Shielding NCRP report No. 17716 on Radiation Protection in Dentistry and Oral and Maxillofacial Imaging recommendation 19 states: “Thyroid shielding shall be provided for patients when it will not interfere with the examination.” The thyroid gland in children is sensitive to radiation-induced cancer.15 Although thyroid cancer risk has not been strongly demonstrated when exposed as adults, it is prudent to consider that the risk exists, albeit lower than in children. Because cancer is a stochastic risk, minimizing dose to the thyroid gland will proportionally decrease thyroid cancer risk. INTRAORAL IMAGING: The estimated thyroid dose from a typical full-mouth radiographic examination is approximately 1 µGy and is reduced by approximately 60% with a thyroid shield.27 The thyroid shield will not interfere with the radiologic examination of the dentoalveolar region and should be used during intraoral radiography. PANORAMIC IMAGING: Estimated thyroid dose is approximately 0.03 µGy to 0.07 µGy,28,29 approximately fifteenfold to thirtyfold lower than with intraoral imaging. Placement of the thyroid collar will block the primary beam and obscure required anatomic detail, so use of thyroid collars for panoramic radiology is not advisable. CBCT IMAGING: Thyroid doses from CBCT examination vary with the field of view (FOV) and the anatomic site examined. The thyroid dose is less than 0.01 µGy with limited FOV maxillary scans to approximately 1.6 µGy for craniofacial captures.16,30,31 Some CBCT units use automated exposure adjustment. These systems evaluate the attenuation on scout images and accordingly set the milliamperage. The presence of a thyroid collar (high X-ray attenuation) on the scout images will result in the system increasing the mA, which will result in increased patient exposure. Thyroid shielding may be used when it will not interfere with anatomic coverage and should be placed on the patient after the scout images have been made.

undergoing dental radiography shall be draped with a protective apron of not less than 0.25 mm lead equivalent to cover the gonadal area” (17 CCR § 30311). This practice was recently questioned by the American Association of Physicists in Medicine (AAPM) position statement advocating for discontinuance of routine use of gonadal and fetal shielding19 and has been endorsed by several professional organizations, including the American College of Radiology,20 the Radiological Society of North America and the Image Gently and Image Wisely Radiation safety campaigns. This changing trend in radiation protection practice has considerable implications for dentistry. The majority of X-ray examinations are done in dental offices — and this positions dentistry as a key player in this trend. 306 M AY

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As these practices evolve in health care, dentists must become informed providers so that they understand the rationale for these changes and can communicate them to patients who may be confused by changing practices. BOX 4 provides relevant data and information to this end. The unit effective dose is used to compare risks from different diagnostic imaging protocols. Effective dose is the sum of the doses to specific at-risk tissues, weighted for their relative stochastic risk. This unit considers the tissues and organs exposed and provides a summation of the estimated stochastic risks weighted based on exposed tissue sensitivities. Because cancer induction is the only risk from diagnostic radiation exposure, an effective dose provides an estimate of the cancer risks. However, there are limitations to

a very rigid interpretation of cancer risks from an effective dose. First, published effective doses (TA BLE 2 ) are broad estimates and individual patient doses will vary based on protocol and patient size. Second, effective dose does not consider age- and gender-associated variations in risks. Nevertheless, this unit provides a convenient measure to compare risks from radiation. TA BLE 2 lists typical effective doses from common dentomaxillofacial imaging procedures and provides an approach for dentists to understand the risks and convey them to patients. Deterministic effects, also termed tissue reactions, occur due to radiation-induced cell killing. Diagnostic X-rays cause negligible cell killing and do not produce clinically evident effects. At higher doses, radiation-induced cell death impairs tissue or organ function and manifests as a detectable effect. The threshold dose, the minimum dose to induce a demonstrable effect, varies with the tissue and effect. When the threshold dose is exceeded, the likelihood of adverse manifestation is high. Moreover, the severity of the effect increases with dose. Deterministic radiation effects are of practical relevance to dentistry — patients with head and neck tumors are managed by radiation therapy, where the high doses cause clinically evident effects. These effects include mucositis, atrophy of the skin and oral mucosa, fibrosis and xerostomia resulting from permanent damage to the salivary gland acini. Sunburn is a classic example of a deterministic effect — it manifests only after a certain amount of sunlight (specifically ultraviolet) exposure and the severity of the burn increases with increasing sunlight exposure. By limiting sunlight exposure, we can prevent the occurrence of sunburn. The same principle is applied in diagnostic imaging. Radiation doses from diagnostic dentomaxillofacial radiologic

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TABLE 2

Step 1: Identify the radiologic examination(s) to be performed. Step 2: Typical effective doses for radiologic examination are listed but are not easily comprehended by lay persons. Rather, convey the doses in terms of “equivalent background days.” Doses from air travel (darkest shaded rows) provide relative comparison with routine life activity and allow patients to place risks into a familiar perspective. Likewise, comparison with other medical imaging procedures also provides a perspective of the relative doses delivered by dentomaxillofacial imaging. The estimated cancer risk provides information on the magnitude of cancer risks. Step 3: Note that the relative radiation levels are higher for children based on their increased sensitivity to radiation-induced cancer. Also note that for all dental imaging procedures, the relative radiation levels are on the lower end of the spectrum.

Communicating Radiation Risks to Patients: Effective Doses and Cancer Risks From Dentomaxillofacial Radiologic Imaging Examination

Effective dose (mSv)a

Equivalent background radiationb

Estimated cancer riskc

Relative radiation levelsd

Adult

Child

Bitewings, 4 images

0.005

< 1 day

1 in 4 million

☢️

Los Angeles to New York City, five-hour air travel

0.015

~ 1.5 days

Panoramic, direct digital

0.02

~ 2 days

1 in a million

Full-mouth X-rays, digital sensor with rectangular collimation

0.03

~ 3 days

1 in 600,000

☢️ ☢

☢️ ☢️ ☢️

Los Angeles to Osaka, 15-hour air travel

0.045

CBCT, limited FOV

0.05

~ 5 days ~ 6 days

1 in 400,000

Full-mouth X-rays, storage phosphor with round collimation

0.1

~ 12 days

1 in 200,000

☢️ ☢☢️

☢ ☢️ ☢ ☢️

Los Angeles to Singapore, round trip, 33-hour air travel

0.1

~ 12 days

CBCT, both jaws with cranium

0.15

~ 2 weeks

1 in 130,000

Mammogram

0.4

~ 7 weeks

1 in 50,000

Multidetector computed tomography, maxillofacial

0.8

~ 14 weeks

1 in 25,000

☢☢️ ☢☢️ ☢☢ ☢️

☢️ ☢️ ☢️ ☢ ☢️ ☢☢ ☢️

Multidetector computed tomography, chest

7.0

~ 2 years

1 in 3,000

☢☢️☢️

☢️ ☢️ ☢️ ☢️

Cephalometric

CBCT, both jaws Chest radiograph

Median effective doses of typical imaging protocols collated from multiple published studies. Equivalent background radiation is based on the average annual U.S. background exposure of 3.1 mSv. c Cancer risk estimated at 5.5%/Sv as per ICRP publication No. 103. d Relative radiation levels. From American College of Radiology, ACR Appropriateness Criteria, www.acr.org/-/media/ACR/Files/Appropriateness-Criteria/ RadiationDoseAssessmentIntro.pdf. a b

examinations are several thousandfold lower than the threshold doses for radiation-induced deterministic effects. Thus, the risk of deterministic effects from dentomaxillofacial radiologic imaging is zero. Cataract induction is a deterministic effect of practical relevance to dental imaging. Cataract induction — lens opacification with

visual impairment— is a scientifically established radiation effect. Recent revaluation of the cataract-inducing effects of radiation estimates the threshold dose at approximately 0.5 Gy to 1 Gy, lower than the previously estimated 2 Gy. Considering these new developments, it has been proposed that lead glasses may provide protection during dentomaxillofacial imaging.

Depending on the imaging procedure and anatomic coverage, the lens dose from dentomaxillofacial imaging ranges from 0.02 mGy to 0.4 mGy, which is 1,200-fold lower than the threshold dose. Thus, the use of lead glasses is not practically necessary. Deterministic effects on the embryo and fetus require additional consideration when imaging a pregnant patient. Animal studies M AY 2 0 2 1

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radiation risk C D A J O U R N A L , V O L 4 9 , Nº 5

BOX 4

Protecting the Gonads: The Changing Landscape of Using Lead Aprons During Radiologic Imaging Current California state regulations require that “Each patient undergoing dental radiography shall be draped with a protective apron of not less than 0.25 mm lead equivalent to cover the gonadal area.” (17 CCR § 30311) The practice of gonadal shielding has been a regular habit in health care for several decades. Written into the U.S. Code of Federal Regulations in 1976, the premise of this precaution was initially based on the belief that radiation exposure to the gonads could result in temporary or permanent sterility or cause germ cell mutations that may manifest as disease in the progeny of the patient. Since then, scientific evidence has demonstrated that the doses needed to effect temporary or permanent sterility in humans are considerably high and that this effect is not a cause for concern in diagnostic imaging. Gonadal doses from dentomaxillofacial imaging, including CBCT, are less than 10 µGy, which is tens of thousandfold lower than the threshold doses needed to cause sterility. Another anticipated risk from gonadal exposure is germ cell mutation that may manifest as hereditary disease in the exposed individual’s offspring. Although demonstrated in animal studies, there is no direct evidence of radiation-induced heritable disease in humans. However, considering the strong evidence of its potential to induce heritable effects in animals, radiation protection agencies continue to consider the risk of heritable effects. The ICRP considers heritable effects to be stochastic with a risk estimate of 0.2% per gray. Gonadal doses from dentomaxillofacial imaging are less than 10 µGy, and thus, heritable risks are practically nonexistent. The above evidence conveys that routine use of gonadal shielding is not practically necessary and does not meaningfully contribute to reducing radiation-associated risks. Several professional health care organizations have advocated that routine use of lead aprons for gonadal shielding during radiologic imaging be discontinued. Note: The effort to discontinue this practice is relatively recent and gonadal shielding is still required by California state law. Dentists must follow this regulation in their practice until such time that California state regulations are amended to such evidence-based practices.

have demonstrated that the preimplantation embryo is highly sensitive to killing by radiation. In humans, embryonic death is unlikely at doses less than 100 mGy.21 Studies of atomic bomb survivors irradiated in utero have identified microcephaly and mental retardation as radiationassociated effects.22–25 These effects occur when in utero radiation occurs before 15 weeks, and the threshold dose for causation is approximately 0.3 Gy. Notably, these doses are several thousandfold lower than estimated fetal doses from dentomaxillofacial imaging. BOX 5 provides data that allow the dentist to evaluate the risks to the embryo and fetus from radiologic imaging. 308 M AY

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Conclusions

When prescribing radiologic imaging, dentists must ensure that the anticipated benefits of imaging will outweigh the radiation-associated risks of cancer induction. Doses delivered by dentomaxillofacial imaging are very low, and dentists who practice appropriate patient selection can very easily tip the scale toward this benefit. n REFERENCES 1. American Dental Association. Dental radiographic examinations: Recommendations for patient selection and limiting radiation exposure. www.ada.org/~/media/ ADA/Member%20Center/FIles/Dental_Radiographic_ Examinations_2012.ashx. Accessed Nov. 16, 2020. 2. American Academy of Oral and Maxillofacial Radiology. Clinical recommendations regarding use of cone beam computed tomography in orthodontics. Position statement by the American Academy of Oral and Maxillofacial Radiology. Oral Surg Oral Med Oral Pathol Oral Radiol 2013 Aug;116(2):238–57. doi: 10.1016/j.oooo.2013.06.002.

3. American College of Prosthodontists. Diagnostic Imaging in the Treatment Planning, Surgical and Prosthodontic Aspects of Implant Dentistry. 2019. www.prosthodontics. org/about-acp/position-statement-diagnostic-imagingtreatment-planning-surgical-prosthodontic-aspects-implantdentistry. Accessed Nov. 17, 2020. 4. Benavides E, Rios HF, Ganz SD, et al. Use of cone beam computed tomography in implant dentistry: The International Congress of Oral Implantologists consensus report. Implant Dent 2012 Apr;21(2):78–86. doi: 10.1097/ ID.0b013e31824885b5. 5. Fayad MI, Nair M, Levin MD, et al. AAE and AAOMR Joint position statement: Use of cone beam computed tomography in endodontics 2015 update. Oral Surg Oral Med Oral Pathol Oral Radiol 2015 Oct;120(4):508–12. doi: 10.1016/j.oooo.2015.07.033. Epub 2015 Aug 3. 6. SEDENTEXCT Consortium. Radiation protection No. 172. Cone beam ct for dental and maxillofacial radiology (evidence-based guidelines). 2011. ec.europa.eu/energy/ sites/ener/files/documents/172.pdf. Accessed Nov. 16, 2020. 7. Tyndall DA, Price JB, Tetradis S, et al. Position statement of the American Academy of Oral and Maxillofacial Radiology on selection criteria for the use of radiology in dental implantology with emphasis on cone beam computed tomography. Oral Surg Oral Med Oral Pathol Oral Radiol 2012 Jun;113(6):817–26. doi: 10.1016/j. oooo.2012.03.005. 8. Langlotz CP. Fundamental measures of diagnostic examination performance: Usefulness for clinical decision making and research. Radiology 2003 Jul;228(1):3–9. doi: 10.1148/radiol.2281011106. 9. Gillies RC, Quinonez C, Wood RE, Lam EWN. Radiograph prescription practices of dentists in Ontario, Canada. J Am Dent Assoc 2021 Feb 23;S0002– 8177(20)30871–0. doi: 10.1016/j.adaj.2020.12.007. Online ahead of print. 10. Hilohi MC, Eicholtz G, Eckerd J, Spelic DC. Nationwide evaluation of X-ray trends (NEXT): Tabulation and graphical summary of the 2014–2015 dental survey; 2019. 11. DentalDisplayQA.com. SMPTE Diagnostic Imaging Test Pattern. 2019. www.dentaldisplayqa.com/content/ knowledge-patterns. Accessed Nov. 16, 2020. 12. National Council on Radiation Protection and Measurements. Evaluation of the relative effectiveness of low-energy photons and electrons in inducing cancer in humans. Bethesda, Md.; 2018. 13. National Council on Radiation Protection and Measurements. Implications of recent epidemiologic studies for the linear-nonthreshold model and radiation protection. Bethesda, Md.; 2018. 14. Mossman KL. The LNT Debate in Radiation Protection: Science vs. Policy. Dose Response 2012;10(2):190–202. doi: 10.2203/dose-response.11-017.Mossman. Epub 2011 Jun 15. 15. National Council on Radiation Protection and Measurements. Scientific committee 1–8 on risk to the thyroid from ionizing radiation, NCRP. Bethesda, Md.; 2009. 16. National Council on Radiation Protection and Measurements. Radiation protection in dentistry and oral and maxillofacial imaging: Recommendations of the National Council on Radiation Protection and

C D A J O U R N A L , V O L 4 9 , Nº 5

BOX 5

Considerations When Imaging a Pregnant Patient Guidance from the ADA indicates that dentomaxillofacial imaging during pregnancy is safe.32 The American College of Radiology practice parameters33 state: “In general, X-ray–based examinations that do not directly expose the pelvis or gravid uterus to the X-ray beam do not require verification of pregnancy status.” The doses from dentomaxillofacial imaging to the fetus is estimated to be 10 µGy or less, 10 to 30 thousandfold lower than threshold doses for noncancer effects. The risk of cancer induction is very low. Thus, imaging may be done during pregnancy. Elective imaging is often deferred until after delivery — to avoid the very low stochastic cancer risk. Note that the major contributor to fetal dose is internal scatter radiation, which cannot be decreased with external protective shielding. Effect

Threshold dosea

Sensitive gestation period

Risk from oral and maxillofacial imaging

Prenatal death

100 µGy

< 10 days

None

Microcephaly

100 µGy

2 to 15 weeks

None

Growth retardation

100 µGy

2 to 15 weeks

None

Mental retardation

300 µGy

8 to 15 weeks

None

Radiation-induced cancer

Noneb

Through pregnancyb

~ 1 in 1.6 million

dmfr.20190014. Epub 2019 Jul 9. 31. Hidalgo A, Davies J, Horner K, Theodorakou C. Effectiveness of thyroid gland shielding in dental CBCT using a paediatric anthropomorphic phantom. Dentomaxillofac Radiol 2015;44(3):20140285. doi: 10.1259/ dmfr.20140285. Epub 2014 Nov 20. 32. American Dental Association. Oral Health Topics: Pregnancy. www.ada.org/en/member-center/oral-healthtopics/pregnancy. Accessed Nov. 16, 2020. 33. American College of Radiology. ACR–SPR Practice parameter for imaging pregnant or potentially pregnant adolescents and women with ionizing radiation. www.acr. org/-/media/ACR/Files/Practice-Parameters/pregnant-pts. pdf Accessed Nov. 16, 2020. 34. Doll R, Wakeford R. Risk of childhood cancer from fetal irradiation. Br J Radiol 1997 Feb;70:130–9. doi: 10.1259/bjr.70.830.9135438. 35. Mandelaris GA, Scheyer ET, Evans M, et al. American Academy of Periodontology best evidence consensus statement on selected oral applications for cone beam computed tomography. J Periodontol 2017 Oct;88(10):939–945. doi: 10.1902/jop.2017.170234. T HE AU T HOR , Sanjay M. Mallya, BDS, MDS, PhD, can be reached at smallya@dentistry.ucla.edu.

Data from ICRP publication 90.21 Assumed stochastic risk.21 c Cancer risk calculated based on the LNT model and an excess absolute risk of 6% per gray.34 a b

Measurements. NCRP report No 177. Bethesda, Md.: 2019. 17. American Thyroid Association. Policy statement on thyroid shielding during diagnostic medical and dental radiology. 2013. www.thyroid.org/wp-content/uploads/ statements/ABS1223_policy_statement.pdf. Accessed Nov. 16, 2020. 18. National Research Council (U.S.). Committee to Assess Health Risks from Exposure to Low Level of Ionizing Radiation. Health risks from exposure to low levels of ionizing radiation : BEIR VII Phase 2. Washington, D.C.: National Academies Press; 2006. 19. American Association of Physicists in Medicine. AAPM position statement on the use of patient gonadal and fetal shielding. 2019. www.aapm.org/org/policies/details. asp?id=468&type=PP. Accessed Nov. 16, 2020. 20. American College of Radiology. ACR endorses AAPM Position on patient gonadal and fetal shielding. 2019. www.acr.org/Advocacy-and-Economics/Advocacy-News/ Advocacy-News-Issues/In-the-June-8-2019-Issue/ACREndorses-AAPM-Position-on-Patient-Gonadal-and-FetalShielding. 21. Streffer C, Shore R, Konermann G, et al. Biological effects after prenatal irradiation (embryo and fetus). A report of the International Commission on Radiological Protection. Ann ICRP 2003;33(1–2):5–206. 22. Lee S, Otake M, Schull WJ. Changes in the pattern of growth in stature related to prenatal exposure to ionizing radiation. Int J Radiat Biol 1999 Nov;75(11):1449–58. doi: 10.1080/095530099139313. 23. Otake M, Fujikoshi Y, Schull WJ, Izumi S. A longitudinal study of growth and development of stature among prenatally exposed atomic bomb survivors. Radiat Res

1993 Apr;134(1):94–101. 24. Otake M, Schull WJ. Radiation-related small head sizes among prenatally exposed A-bomb survivors. Int J Radiat Biol 1993 Feb;63(2):255–70. doi: 10.1080/09553009314550341. 25. Schull WJ, Otake M. Learning disabilities in individuals exposed prenatally to ionizing radiation: The Hiroshima and Nagasaki experiences. Adv Space Res 1986;6(11):223– 32. doi: 10.1016/0273-1177(86)90296-6. 26. Schwendicke F, Tzschoppe M, Paris S. Radiographic caries detection: A systematic review and meta-analysis. J Dent 2015 Aug;43(8):924–33. doi: 10.1016/j. jdent.2015.02.009. Epub 2015 Feb 24. 27. Johnson KB, Ludlow JB. Intraoral radiographs: A comparison of dose and risk reduction with collimation and thyroid shielding. J Am Dent Assoc 2020 Oct;151(10):726–734. doi: 10.1016/j. adaj.2020.06.019. 28. Han GS, Cheng JG, Li G, Ma XC. Shielding effect of thyroid collar for digital panoramic radiography. Dentomaxillofac Radiol 2013;42(9):20130265. doi: 10.1259/dmfr.20130265. Epub 2013 Sep 4. 29. Ludlow JB, Davies-Ludlow LE, White SC. Patient risk related to common dental radiographic examinations: The impact of 2007 International Commission on Radiological Protection recommendations regarding dose calculation. J Am Dent Assoc 2008 Sep;139(9):1237–43. doi: 10.14219/jada.archive.2008.0339. 30. Pauwels R, Horner K, Vassileva J, Rehani MM. Thyroid shielding in cone beam computed tomography: Recommendations toward appropriate use. Dentomaxillofac Radiol 2019 Oct;48(7):20190014. doi: 10.1259/ M AY 2 0 2 1

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cone beam ct C D A J O U R N A L , V O L 4 9 , Nº 5

Cone Beam Computed Tomography and Radiographs for Endodontics: A Pictorial Illustration of the AAE-AAOMR Position Statement Rumpa Ganguly BDS, DMD, MS, and Mike Sabeti, DDS, MA

abstract Background: Cone beam computed tomography (CBCT) has become an integral part of more challenging and complex endodontic treatments. CBCT may be considered in the presence of specific signs and symptoms when clinical questions are not addressed by conventional 2D radiographic imaging. Results: This article provides pictorial illustrations of endodontic cases where CBCT, imaging, when performed with appropriate imaging protocol, may lead to informed decision-making regarding treatment approaches of the more challenging endodontic cases. The illustrations are based on recommendations made by the AAE-AAOMR position statement. Practical implications: This pictorial essay elaborates the recommendations in the joint position statement of the AAE-AAOMR through illustrated case scenarios to help clinicians understand the impact of CBCT on diagnosis and treatment planning. Key words: Cone beam CT, CBCT, endodontics, AAE-AAOMR position statement recommendations

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AUTHORS Rumpa Ganguly BDS, DMD, MS, is an oral and maxillofacial radiologist and a diplomate of the American Board of Oral and Maxillofacial Radiology. She is an associate professor of clinical orofacial sciences and director of the oral and maxillofacial radiology clinic at the University of California, San Francisco, School of Dentistry. Conflict of Interest Disclosure: None Reported.

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Mike Sabeti, DDS, MA, is an endodontist and is a diplomate of the American Board of Endodontics. He is a professor of preventive and restorative dental sciences and the program director of the graduate endodontics program at the University of California, San Francisco, School of Dentistry. Conflict of Interest Disclosure: None Reported.

adiographic imaging plays a crucial role in endodontic treatment. The goal of radiographic imaging is to acquire high-quality images of the teeth and surrounding structures for diagnosis, treatment and monitoring of care. The most common radiograph ordered for endodontic diagnosis and postoperative follow-up is a periapical radiograph. A diagnostic periapical radiograph made using proper technique and exposure settings displays the width and height of the tooth structure and periapical bone. The apical structures of the teeth such as lamina dura and periodontal ligament space can be depicted accurately and with great clarity provided the projection geometry is accurate for the structures under investigation. Over the past decade, dentistry has witnessed rapid migration from film-based imaging to digital imaging due to the demand for electronic health records and stricter environmental laws for handling, disposing and treating chemicals and materials used in film-based imaging. Digital imaging technology has improved over the last two decades with lower costs and more product availability. However, the inherent limitation of periapical radiography, whether film-based or digital, is the lack of information in the transverse plane or in the buccolingual plane leading to limited diagnostic information in those situations where diagnosis requires a multidimension visualization of the tooth and surrounding structures. Although this information may not be necessary in most routine cases of endodontic treatment, the determination of an existing anomaly or abnormal findings may alter the clinician’s treatment approach.1 Cone beam computed tomography

(CBCT) allows multidimensional visualization of teeth and adjoining anatomy and has transformed endodontic diagnostic capability.2–4 Current CBCT machines provide varying options for field of view (FOV), voxel sizes, exposure settings, gantry rotation angle and number of projection frames acquired in a single rotation of the gantry. These factors have an impact on both diagnostic image quality and radiation dose to the patient. Clinicians must exercise discretion and professional judgement to select the most appropriate FOV, voxel size and exposure settings that accomplish the diagnostic objective with the least amount of radiation. An appropriately designed examination ensures that the anticipated diagnostic benefits will outweigh the risks. For endodontic diagnostic purposes, the area of interest is typically limited to a single tooth or the adjacent teeth within a sextant, thus a limited FOV provides adequate coverage. Additionally, endodontic diagnostic assessments involve evaluation of structural details such as lamina dura, PDL space and narrow root canals thus requiring high spatial resolution to accomplish the diagnostic objectives. This manuscript lists the 14 CBCT imaging recommendations published in the joint position statement of the American Academy of Endodontics (AAE) and the American Academy of Oral and Maxillofacial Radiology (AAOMR).5 We summarize the essential elements of evidence that form the basis for these recommendations. Using illustrative cases, we demonstrate how proper patient selection and appropriate CBCT imaging provide value in decision-making for a variety of challenging endodontic situations.

C D A J O U R N A L , V O L 4 9 , Nº 5

Recommendation 1: Intraoral radiographs should be considered the imaging modality of choice in the evaluation of the endodontic patient.5 Rationale: For most common pulp and periapical diseases, clinical evaluation and radiologic information provide adequate information for successful diagnosis and management. Intraoral radiographs provide the needed diagnostic benefit at lower radiation and cost. Case 1 A 36-year-old-female presented for root canal treatment of the mandibular incisors. Clinical exam of teeth Nos. 23–26 revealed porcelain fused to metal crowns in place. These teeth were not sensitive to percussion or palpation and did not respond to a cold test. A periapical radiograph was made with the crowns in place and again after their removal. The periapical radiographs showed widening of the apical periodontal ligament (PDL) space of these teeth with a periapical radiolucent area of teeth Nos. 24 and 26 consistent with apical rarefying osteitis (granuloma or cyst). Root canal treatment was performed successfully based on the diagnostic information available in these periapical radiographs (FIGURES 1 ). Recommendation 2: Limited FOV CBCT should be considered the imaging modality of choice for diagnosis in patients who present with contradictory or nonspecific clinical signs and symptoms associated with untreated or previously endodontically treated teeth.5 Rationale: Studies have shown that periapical lesions appear earlier in CBCT images compared to periapical radiographs.6 Success of endodontic treatment is higher when teeth are treated before appearance of radiographic

FIGURE S 1. Periapical radiographs of mandibular anterior teeth with porcelain fused to metal crowns in place (1A ) and after their removal (1B ) showing periapical radiolucent area of teeth Nos. 24 and 26

with widening of the apical periodontal ligament (PDL) space. Teeth Nos. 23 and 25 show widening of the apical PDL space without a periapical radiolucent area.

signs of periapical disease.6 Studies have also shown higher detection rates of primary endodontic disease with CBCT when compared with periapical radiography both via in vivo and ex vivo studies.8–12 Further, CBCT is better than periapical imaging for differentiation of atypical odontalgia from symptomatic apical periodontitis.13,14 Case 2 Contradictory or nonspecific clinical signs and symptoms associated with a previously endodontically treated tooth. A 62-year-old female presented with a persistent periapical radiolucent lesion of tooth No. 21 post-endodontic treatment. Periapical radiographs and CBCT from over a two-year period were reviewed. There was a periapical radiolucent area associated with teeth Nos. 21 and 22 that appeared to have minimally reduced in size over the two years since the endodontic treatment of tooth No. 21. A limited FOV CBCT was obtained and compared to a previous CBCT from a year prior to investigate the possibility of a fracture of tooth No. 21, but no evidence of a fracture was noted. Clinical exam revealed that teeth Nos. 21 and 22 were

negative to percussion and palpation with no mobility. The probing depths were within normal limits with no bleeding upon probing. No swelling or sinus tract was noted. The patient presented with contradictory or nonspecific clinical signs and symptoms for tooth No. 21. A definitive diagnosis could not be reached based on the clinical and radiographical evaluation. A biopsy was ordered to determine the confirmatory diagnosis of the periapical lesion (FIGURES 2 ). Recommendation 3: A limited FOV CBCT should be considered the imaging modality of choice for initial treatment of teeth with the potential for extra canals and suspected complex morphology, such as mandibular anterior teeth, maxillary and mandibular premolars and molars and dental anomalies.5 Rationale: The inherent limitations of 2D imaging in displaying anatomical variations of roots and the root canal system may lead to lack of complete data for a successful root canal therapy. Data from CBCT showed a strong correlation with sectioning and histologic examination of teeth depicting the actual number of roots and canals;14,15 specificity M AY 2 0 2 1

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cone beam ct C D A J O U R N A L , V O L 4 9 , Nº 5

■

FIGURE S 2 . Pretreatment periapical radiograph of teeth Nos. 21 and 22 (2A ) showing a periapical radiolucent

area associated with teeth Nos. 21 and 22 with loss of apical lamina dura consistent with apical rarefying osteitis. Reconstructed panoramic view from a limited FOV CBCT volume at one-year post-treatment follow-up (2B ) and twoyear follow-up post-treatment (2C ) shows the minimally changed periapical radiolucent area of teeth Nos. 21 and 22. Axial CBCT (2D ) from two-year follow-up shows the minimally expansile periapical lesion.

and sensitivity in detecting the second mesiobuccal (MB2) canal is higher with CBCT than with intraoral radiography.17 Case 3 Missed canal in a previously treated tooth. A 61-year-old female presented with pain in the lower anterior region. On clinical exam, teeth Nos. 23 and 24 were sensitive to percussion and palpation with grades 1 to 2 mobility. A periapical radiograph revealed a periapical radiolucent area with loss of lamina dura of teeth Nos. 23 and 24. There appeared to be a radiolucent area superimposed over the apical half of the root of tooth No. 24. A limited FOV CBCT revealed a large periapical radiolucent area around teeth Nos. 23 and 24. Tooth No. 24 also had large external resorption at midroot level on the lingual. No buccal bone was present on tooth No. 24. Widening of the 314 M AY

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PDL space was seen on teeth Nos. 23 and 24. Tooth No. 23 had been endodontically treated previously and seemed to have a lingual canal that was inadequately prepared and filled (FIGURES 3 ). Recommendation 4: If a preoperative CBCT has not been taken, limited FOV CBCT should be considered as the imaging modality of choice for intra-appointment identification and localization of calcified canals.5 Rationale: ■ Anatomical variations exist among different types of teeth. The success of nonsurgical root canal therapy depends on identification of canals, cleaning, shaping and obturation of root canal systems as well as the quality of the final restoration. ■ 2D imaging does not consistently reveal the actual number of roots

and canals. In studies, data acquired by CBCT showed a very strong correlation between sectioning and histologic examination.15,16 In a 2013 study, CBCT showed higher mean values of specificity and sensitivity when compared to intraoral radiographic assessments in the detection of the MB2 canal.17

Case 4 Identification and localization of calcified canals. A 64-year-old male presented to our clinic with a chief complaint of “I have pain in my upper left jaw.” Clinical exam revealed that tooth No. 14 was negative to a thermal test, positive to percussion and palpation and no swelling or sinus tract was noted. There was no mobility of tooth No. 14 and probing depths were within normal limits. A periapical radiograph of tooth No. 14 revealed a periapical radiolucent area with loss of lamina dura consistent with apical rarefying osteitis. Clinically, tooth No. 14 was diagnosed as necrotic with symptomatic apical periodontitis. The tooth was anesthetized and isolated with a rubber dam and root canal treatment was initiated, but the clinician was unable to locate the mesiobuccal (MB) canals due to calcification of the canals. A limited FOV CBCT was acquired for further investigation and both MB1 and MB2 were identified and negotiated (FIGURES 4 ). Recommendation 5: Intraoral radiographs should be considered the imaging modality of choice for immediate postoperative imaging.5 Case 5 Immediate postoperative imaging. A 45-year-old-female presented for an 18-month follow-up postendodontic

C D A J O U R N A L , V O L 4 9 , Nº 5

FIGURE S 3 . Periapical radiograph of teeth Nos. 23 and 24 (3A ) shows endodontically treated tooth No. 23 with loss of apical lamina dura and a periapical radiolucency. A periapical lesion is also noted on tooth No. 24 along with a radiolucent defect in the middle third of the root. Limited FOV axial CBCT image (3B ) and sagittal CBCT image (3C ) reveal a missed accessory root canal in previously treated tooth No. 23. The periapical radiolucent area of tooth No. 23 is noted.

FIGURE S 4 . Periapical radiograph of tooth No. 14 (4A ) shows a periapical radiolucent area with loss of apical lamina dura associated with the mesiobuccal (MB ) root. Limited FOV sagittal CBCT image (4B ) shows the periapical radiolucent area of the MB root, thinning and elevation of the adjacent floor of the maxillary sinus and soft tissue thickening within the sinus. Axial CBCT image of tooth No. 14 (4C ) shows MB1 and MB2 canals that were not identified during initial access of the tooth due to calcification.

treatment of tooth No. 5. The patient was asymptomatic. A periapical radiograph showed normal trabecular pattern and density of periapical bone of endodontically treated tooth No. 5. The comparison of the progressively reducing size of the periapical radiolucent lesion of tooth No. 5 in the pretreatment, immediate postoperative and 18-month follow-up periapical radiographs can be made (FIGURES 5 ). Recommendation 6: Limited FOV CBCT should be considered the imaging modality of choice if clinical examination and 2D intraoral radiography are inconclusive in the detection of vertical root fracture.5

Rationale: CBCT has been shown to exhibit higher sensitivity (88%) and specificity (75%) in detection of vertical root fractures in a clinical study where definitive fracture was diagnosed at the time of surgery.18 Several in vivo and laboratory studies have also found CBCT to have higher accuracy, specificity and sensitivity in detection of vertical root fractures, identified through its consequent periradicular bone loss.19,20 However, detection of fracture is dependent on the size of the fracture, the presence of artifacts caused by endodontic filling material and the spatial resolution of the CBCT image. Nevertheless, the use of CBCT may improve the odds of obtaining an accurate

diagnosis that can affect both the choice of treatment options and the outcome. Case 6 Vertical root fracture. A 77-year-old male patient presented with a fractured mesio-occlusal (MO) amalgam restoration of tooth No. 2 and an isolated deep probing depth of 14 mm. Cold test was negative, percussion was positive and no tooth mobility was detected on clinical testing. A periapical radiograph of tooth No. 2 showed an ill-defined periapical radiolucent area with loss of lamina dura and widening of the PDL space. The lesion appeared to extend into the maxillary M AY 2 0 2 1

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cone beam ct C D A J O U R N A L , V O L 4 9 , Nº 5

FIGURE S 5 . Pretreatment periapical radiograph of tooth No. 5 (5A ) showing the periapical radiolucent area of tooth No. 5 with loss of apical lamina dura. Immediate postoperative periapical radiograph (5B ) showing obturated buccal and palatal root canals of tooth No. 5 with the previously noted periapical radiolucency. The periapical radiograph at 18-month follow-up (5C ) shows normal trabecular pattern and density of the periapical bone of tooth No. 5.

FIGURE S 6 . Periapical radiograph (6A ) shows loss of apical lamina dura, widening of the PDL space and periapical radiolucency of tooth No. 2 extending into the area of the maxillary sinus. The floor of the maxillary sinus appears intact but elevated. Limited FOV CBCT axial image (6B ) shows a radiolucent line extending mesiodistally involving MB and DB roots representing vertical root fractures. Coronal CBCT (6C ) shows the course of the vertical root fracture involving the DB root (arrows) extending possibly from the area of clinically noted fractured restoration to the furcation region. A radiolucent area in the periapical and furcation regions noted with discontinuity of the floor of maxillary sinus and soft tissue thickening in the maxillary sinus representing sinusitis (arrowhead). Coronal CBCT slice (6D ) shows the course of the vertical fracture in the MB root. Sagittal CBCT slice (6E ) shows extensive radiolucent areas peripheral (arrows) and apical to roots of tooth No. 2 representing severe periodontal bone loss.

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sinus. The floor of the maxillary sinus appeared intact but elevated. The roots appeared superimposed over one another, although no peripheral bone loss along the roots was seen. Small FOV CBCT volume of tooth No. 2 was made for further assessment. Axial and coronal CBCT views revealed a vertical root fracture extending mesiodistally between the MB and DB roots. Extensive periodontal bone loss was noted along all the roots extending apically with disruption of the floor of the maxillary sinus as noted in coronal and sagittal CBCT slices. Soft tissue thickening was noted in the adjoining maxillary sinus representing odontogenic sinusitis (FIGURES 6). Recommendation 7: Limited FOV CBCT should be the imaging modality of choice when evaluating the nonhealing of previous endodontic treatment to help determine the need for further treatment, such as nonsurgical, surgical or extraction.

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Rationale: A higher number of periapical lesions was reported with posttreatment recall CBCT imaging (25%) compared to periapical radiographs (12%), according to a study by Liang et al.21 These results concur with similar studies.22–24 Additionally, 80% of apparently short root fillings based on periapical radiographs appeared flush on CBCT. Periapical radiographs revealed voids in endodontic filling in 16% of cases whereas CBCT revealed voids in 46% of cases.21 The accuracy of diagnosis reached with CBCT was approximately twice that of periapical radiographs. A change in diagnosis and treatment plan was noted in 56% to 66% of cases in a study comparing periapical radiographs and CBCT imaging, and in 62% of cases, treatment plan modifications were made due to additional information acquired from the CBCT data.25 Case 7 Nonhealing previously treated tooth. A 38-year-old male presented with a chief complaint of pain and swelling in the maxillary left posterior region for the past month while on antibiotics. A clinical exam revealed that tooth No. 14 was tender on percussion and palpation associated with swelling of the surrounding soft tissues. Tooth No. 14, which had a full-coverage ceramic restoration, had been endodontically treated. A limited FOV CBCT volume revealed a previous apicoectomy of the MB root system with a long bevel and blunting of the apex of the MB root. A radiolucent area associated with the surgical endodontic access site of the MB root system was noted. No instrumentation of the MB2 canal was noted. Tooth No. 14 was diagnosed as an acute apical abscess with previous root canal treatment (RCT) and apicoectomy. RCT was recommended due to a missed MB2 canal (FIGURES 7 ).

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FIGURE S 7. Periapical radiograph of tooth No. 14 (7 A ) shows endodontically treated tooth No. 14 with full-

coverage ceramic restoration. Blunting of the root apex of MB root with an ill-defined periapical radiolucent area is noted. Sagittal image slice of limited FOV CBCT (7 B ) reveals a periapical radiolucent area associated with MB root system. Sclerosis of surrounding trabecular bone noted representing sclerosing osteitis. Cross-sectional CBCT slice (7 C ) reveals blunting of the apex of MB root with complete loss of buccal cortex in the area of the radiolucency (arrow). Axial CBCT slice (7 D ) shows missed MB2 canal (arrow) and obturated remaining canals in tooth No. 14.

Recommendation 8: Limited FOV CBCT should be the imaging modality of choice for nonsurgical retreatment to assess endodontic treatment complications, such as overextended root canal obturation material, separated endodontic instruments and localization of perforations.5 Rationale: The 3D spatial location of a separated instrument or perforation and its relationships to vital structures are important elements for treatment planning and for prognosis. Case 8A Overextended root canal obturation material. A 41-year-old presented with previously treated tooth No. 30 with a distobuccal sinus tract. Clinical exam revealed that the tooth was slightly tender to percussion and negative to palpation. The porcelain

fused to metal crown was intact. A gutta percha point was used to trace the sinus tract to the distal root in a periapical radiograph. The periapical radiograph of tooth No. 30 revealed a radiolucent area surrounding mesial and distal root apices. Extruded sealer was noted at the apex of the mesial canal. Tooth No. 30 was diagnosed as previously treated with chronic apical abscess. Limited FOV CBCT imaging revealed radiolucent areas surrounding mesial and distal apices. Extruded sealer was noted beyond the MB apical foramen. One untreated distal canal was noted (FIGURES 8A ). Case 8B Separated endodontic instruments. A 63-year-old female presented with an endodontically treated tooth M AY 2 0 2 1

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FIGURE S 8A . Periapical radiograph of tooth No. 30 (1 ) shows endodontically treated tooth No. 30 with porcelain fused to metal crown in place. Periapical radiolucent area associated with mesial and distal roots and extruded sealer noted at the mesial root apex. Limited FOV CBCT sagittal slice (2 ) shows sealer extruded at the apex of the mesial canal and the surrounding radiolucent area. Axial CBCT image (3 ) shows a lingually located missed distal canal in the distal root of tooth No. 30 (arrow) with

localized bone loss on the distal surface of the distal root.

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8B3 FIGURE S 8B . Periapical radiograph of tooth No. 18 (1 ) shows endodontically treated tooth No. 18 with a

periapical radiolucent area and a linear high-density object consistent with a separated instrument extruding into the periapical area of the distal root. Reconstructed panoramic image from a limited FOV CBCT (2 ) shows the periapical radiolucency and cross-sectional image slices of CBCT of tooth No. 18 (3 ) shows the separated instrument extruded from the distal root apex into the periapical area. The periapical lesion appears to be in close proximity to the inferior alveolar nerve canal.

No. 18 that remained symptomatic with tenderness on percussion and palpation. Tooth No. 18 was diagnosed as previously treated with symptomatic apical periodontitis. A periapical radiograph showed foreign material extending beyond the distal root apex of tooth No. 18 and a periapical 318 M AY

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radiolucent lesion consistent with apical rarefying osteitis (abscess, granuloma or cyst). A limited FOV CBCT volume revealed a linear high-density object consistent with a separated instrument in the distal root apex, which extended into the periapical region (FIGURES 8B ).

Case 8C Localization of perforations. A 50-year-old female presented with an endodontically treated tooth No. 3. A periapical radiograph of tooth No. 3 showed a periapical radiolucent area associated with the mesial root with widening of the periodontal ligament (PDL) space. The apical third of the mesial root was devoid of endodontic filling material. The tooth was sensitive to percussion and palpation. Clinically, tooth No. 3 was diagnosed as previously treated with symptomatic apical periodontitis. A limited FOV CBCT was acquired. The reconstructed thin section panoramic view showed the periapical radiolucent area with peripheral bone loss along the mesial root. There was also transportation and perforation of the MB2 root at the midroot level as shown in the axial and sagittal CBCT images (FIGURES 8C ). Recommendation 9: Limited FOV CBCT should be considered as the imaging modality of choice for presurgical treatment planning to localize root apex/apices and to evaluate the proximity to adjacent anatomical structures.5 Rationale: The use of CBCT has been recommended for treatment planning of endodontic surgery.26,27 CBCT visualization of the true extent

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of periapical lesions and their proximity to important vital structures and anatomical landmarks is superior to that of periapical radiographs. Potential morbidity from inadvertent violation of vital anatomic boundaries is high. Case 9A Proximity of root apex to inferior alveolar nerve canal. A 68-year-old female presented with pain in the left posterior region of the mandible. Tooth No. 19 was tender on palpation and percussion and had swelling of the adjacent soft tissues. Tooth No. 19 responded negatively to a cold test. A periapical radiograph revealed widening of the apical PDL space and a periapical radiolucent area that was surrounded by sclerosis of the trabecular bone consistent with sclerosing osteitis. A clinical diagnosis of necrotic pulp with acute apical abscess and possible osteomyelitis was made. A limited FOV CBCT of tooth No. 19 confirmed the periapical radiolucent area with surrounding sclerosis consistent with sclerosing osteitis or focal sclerosing osteomyelitis. Additionally, a moderate caliber accessory neurovascular channel or a nutrient canal was noted extending from the distal root to the inferior alveolar nerve canal (FIGURES 9A ). The risk of paresthesia following treatment was reviewed and communicated to the patient. Case 9B Proximity of periapical lesion to inferior alveolar nerve canal and lingual cortical plate of mandible. A 68-year-old male presented for a five-year recall postendodontic treatment of tooth No. 18. The patient was asymptomatic. Tooth No. 18 tested normal on palpation, percussion and mobility testing. An isolated 10 mm pocket was noted lingual to the tooth.

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FIGURE S 8C . Periapical radiograph of tooth No. 3 (1 ) shows endodontically treated tooth No. 3 with a periapical radiolucent area of the mesial root and widening of the PDL space along the mesial root. Apical third of the mesial root appears devoid of endodontic filling material. Thin section panoramic reconstruction of limited FOV CBCT (2 ) and sagittal CBCT image slice (3 ) show apical canal transportation of MB2 with bone loss along the mesial root surface of MB root. Axial CBCT (4 ) of tooth No. 3 shows the location of the apical transportation of MB2 on the mesial surface of MB root (arrow).

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FIGURE S 9A . Periapical radiograph (1 ) of tooth No. 19 shows widening of apical PDL and an apparent

periapical radiolucent area surrounded by extensive sclerosis of trabecular bone representing sclerosing osteitis. M area periapical to Reconstructed thin section panoramic image from limited FOV CBCT (2 ) shows the radiolucent the distal root of tooth No. 19 along with associated sclerosing osteitis. There is a radiolucent channel extending from the apical region of the distal root to the inferior alveolar nerve (IAN) canal consistent with an accessory neurovascular branch of an IAN canal or a nutrient canal.

A periapical radiograph revealed a radiolucent area associated with the mesial and distal root apices that was stable in size on comparing with previous images. The tooth was diagnosed as an endodontically treated tooth with asymptomatic apical periodontitis. A limited FOV CBCT of tooth No. 18 was

made to further investigate S the reason for the deep pocket. CBCT revealed previous endodontic treatment of tooth No.18 with three obturated canals. Obturation appeared adequate in length, taper and density. Radiolucent areas around the mesial and distal apices were noted with perforation of the lingual cortical plate M AY 2 0 2 1

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9B4 FIGURE S 9B . Periapical radiograph (1 ) of tooth No. 18 was made as a part of the five-year recall

postendodontic treatment follow-up. A stable periapical radiolucent area was noted to be associated with the mesial and distal root apices consistent with post-treatment changes. Axial CBCT slice (2 ) shows radiolucent area distal to the mesial root representing bone loss with loss of lingual cortical plate at this location. Sagittal CBCT slice (3 ) shows periapical radiolucent lesion associated with the mesial and distal roots and radiolucent lines in the mesial root and across pulpal floor consistent with fractures (arrows). Cross-sectional CBCT slices (4 ) show the buccolingual extent of the periapical radiolucent lesion and its close proximity to the inferior alveolar nerve canal (arrow).

distal to the roots. A fracture line was identified on the pulpal floor extending from the mesial root to the distal canal. The radiolucent lesion measured approximately 8 mm by 8 mm by 8 mm and was in close proximity to the inferior alveolar nerve canal (FIGURES 9B ). Case 9C True extent of periapical lesions and their proximity to important vital structures. A 61-year-old male presented with a sinus tract on tooth No. 13. The tooth had been treated with nonsurgical root canal therapy. Tooth No. 13 was diagnosed with chronic apical abscess. A periapical radiograph of tooth No. 13 showed an endodontically treated tooth No. 13 with a periapical radiolucent lesion, however, 320 M AY

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the full extent of the lesion could not be seen in this radiograph. A limited FOV CBCT was acquired. CBCT images showed an expansile radiolucent lesion associated with the apex of tooth No. 13 close to the maxillary sinus. The floor of the sinus adjacent to the lesion was displaced with extreme thinning and possible perforation. Loss of the buccal cortex adjacent to the lesion was noted. Soft tissue thickening in the maxillary sinus adjoining the periapical lesion of tooth No. 13 was noted and consistent with sinusitis (FIGURES 9C ). Recommendation 10: Limited FOV CBCT should be considered as the imaging modality of choice for surgical placement of implants.5,28

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Case 10 Dental implant. A 50-year-old female presented for presurgical planning of dental implant placement in the area of missing teeth Nos. 12 and 13. A periapical radiograph of the region showed a normal trabecular pattern of bone with no evidence of pathosis; however, the assessment of the quantity of available bone in the region and the location of the floor of the maxillary sinus could not be assessed from this image. A limited FOV CBCT was acquired. The axial image slice of the CBCT showed the length of the edentulous span and the reference line perpendicular to the arch in the image referred to the location of the cross-sectional CBCT image slice. The cross-sectional image slice is vital to the preoperative assessment of the dental implant site. This image slice shows the morphology of the residual alveolar ridge in the buccolingual plane, the location of the floor of the maxillary sinus and the orientation of the long axis of the residual alveolar ridge. The measurement of the available height from the floor of the sinus and width of the residual alveolar ridge near the alveolar crest is shown in the image slice (FIGURES 10 ). Recommendation 11: Limited FOV CBCT should be considered the imaging modality of choice for

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FIGURE S 9C. Periapical radiograph of endodontically treated tooth No. 13 (1 ) showing a periapical radiolucent lesion. The full extent of the lesion cannot be seen in this

radiograph. A reconstructed thin section panoramic image from a limited FOV CBCT volume (2) show the well-defined corticated margin of the periapical lesion of tooth No. 13, displacing the floor of the left maxillary sinus superiorly. There appears to be thinning and possible breaks in the periphery of the lesion. Moderate soft tissue thickening of the adjoining maxillary sinus is noted consistent with sinusitis. Cross-sectional CBCT slices of tooth No. 13 (3) show the displaced and extremely thin floor of the maxillary sinus adjoining the lesion and loss of buccal cortex (arrows).

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FIGURE S 10. Periapical radiograph (1 0 A) showing normal trabecular pattern in the area of missing teeth Nos. 12 and 13. The axial image slice from the limited FOV CBCT (10B) shows the length of the edentulous span and the reference line perpendicular to the arch correlates to the location of the cross-sectional CBCT image slice (10C). Cross-sectional CBCT slice (10C ) of the area of missing tooth No. 13 shows the available height of bone from the floor of the maxillary sinus to the crest of the residual alveolar ridge. The width of the ridge near the crest is also provided.

diagnosis and management of limited dentoalveolar trauma, root fractures, luxation and/or displacement of teeth and localized alveolar fractures in the absence of other maxillofacial or soft tissue injury that may require other advanced imaging modalities.29 Case 11 Traumatic injuries — horizontal root fracture. A 62-year-old male presented with a swelling in the facial aspect of tooth No. 8. The patient reported that tooth No. 8 was endodontically treated several years prior following a facial trauma. A periapical radiograph revealed an endodontically treated tooth No. 8, obturated to the apex but with widening of the apical PDL space and a radiolucent area mesial of the

apical region of this tooth. The lesion had progressively increased in size over the years as seen in comparison radiographs. A limited FOV CBCT revealed a horizontal fracture line in the buccal aspect of the root, 5 mm from the apex. Bone loss was noted on the facial, lingual and mesial surfaces of tooth No. 8 presenting as a wide radiolucent area around the root with the loss of facial cortex. Bone loss was seen in the vicinity of the noted horizontal fracture (FIGURES 11 ). Endodontic diagnosis was previous endodontic treatment with acute apical abscess and a horizontal fracture. Recommendation 12: Limited FOV CBCT is the imaging modality of choice in the localization and differentiation of external and internal resorptive

defects and the determination of appropriate treatment and prognosis.30,31 Case 12 Resorptive defects. A 65-year-old- male presented with a chief concern of, “I was told I need to see endodontists to see if they can save my tooth.” A periapical radiograph showed an ovoid radiolucent area in the cervical region of tooth No. 11. The shadow of the pulp could be distinguished from the ovoid radiolucent area. A limited FOV CBCT of tooth No. 11 was acquired. CBCT images showed a radiolucent area in the cervical region of tooth No. 11 with palatal entry involving the palatal tooth surface and continuity with the pulp consistent with invasive M AY 2 0 2 1

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FIGURE S 11. Periapical radiograph (11A ) of endodontically treated tooth No. 8 obturated to the apex showing widening of the apical PDL space and a periapical radiolucent area extending to the mesial of the apex. Sagittal slice of a limited FOV CBCT (11B ) shows tooth No. 8 with widening of apical PDL space, loss of buccal cortex

on the apical third and a horizontal radiolucent line extending from the treated root canal to the buccal root surface consistent with a horizontal root fracture. Axial CBCT slice (11C ) of the limited FOV CBCT shows a radiolucent area of bone loss on the mesial and facial aspect of the root of tooth No. 8.

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FIGURE S 12 . Periapical radiograph (1 2 A) of tooth No. 11 shows an ovoid radiolucent area in the cervical region superimposed over the shadow of the root canal;

however, the two shadows can be distinguished from each other. Sagittal slice of limited FOV CBCT (1 2 B ) shows a radiolucent defect extending from the palatal tooth surface in cervical region of No. 11 to the root canal. There does not appear to be expansion of the pulpal walls of the root canal. Axial CBCT slice (1 2 C ) shows the area of resorption in tooth No. 11 extending from the palatal surface to the root canal consistent with invasive external resorption.

external resorption. Clinically, there appeared to be a pinkish area that was in communication with the lesion with the palatal point of entry (FIGURES 12 ). Recommendation 13: In the absence of clinical signs or symptoms, intraoral radiographs should be considered the imaging modality of choice for the evaluation of healing following nonsurgical and surgical endodontic treatment.32 For most typical endodontic management, clinical and historical information and periapical radiographs 322 M AY

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provide adequate information to assess successful treatment outcome.

CBCT imaging to facilitate evaluation of post-treatment changes, as necessary.

Recommendation 14: In the absence of signs and symptoms, if limited FOV CBCT was the imaging modality of choice at the time of evaluation and treatment, it may be the modality of choice for follow-up evaluation. In the presence of signs and symptoms, refer to Recommendation 7.32 Evaluation of the periapical bone is one component in endodontic outcome assessment. Clinicians may use judgement and, where appropriate, use

Discussion

CBCT imaging has the potential to provide information of value to a successful outcome of endodontic treatment. However, appropriate patient selection is a key element to its effective use. The AAE-AAOMR recommendations for patient selection provide guidance to selecting the most appropriate situations that would likely benefit from CBCT imaging. It is also important to recognize that CBCT

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information may be inconclusive or may not provide the anticipated additional information. Beyond patient selection and optimization of the imaging protocol, the value of the diagnostic imaging is provided by the dentist’s evaluation and interpretation of the findings. Dentists who use CBCT imaging must be skillful in interpreting these images. This requires knowledge of the radiographic anatomy, pathology and an understanding of the CT image formation. For example, the dentist must recognize that artifacts generated by metallic dental restorations, implants and high-attenuation endodontic restorative materials can negatively impact image interpretation. Such artifacts manifested as streaks and dark bands are referred to as “beam hardening artifacts.” Some vendors provide software tools that manipulate CT image reconstruction to reduce the appearance of these artifacts. However, such approaches also alter and can potentially decrease diagnostic information. Dentists who use these tools must be aware of these inadvertent effects and apply such image correction tools with caution.

Conclusion

This pictorial essay demonstrates that the recommendations in the joint AAEAAOMR position statement on the use of CBCT in endodontics are a rational and effective approach to implementing CBCT technology in endodontics. Although CBCT is associated with higher radiation levels than traditional periapical radiography, this technology offers vital information to improve the diagnosis of the dental clinician in keeping with the ALARA principle of radiation protection for better patient outcomes. The benefits of additional information obtained with CBCT may in many cases justify the increase in radiation exposure. n

RE FE RE N C E S 1. Roda RS. Can use of cone beam computed tomography have an effect on endodontic treatment? J Calif Dent Assoc 2018 Apr;46 (4):237–46. 2. Lofthag-Hansen S, Huumonen S, Grondahl K, Grondahl HG. Limited cone beam CT and intraoral radiography for the diagnosis of periapical pathology. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2007 Jan;103(1):114–9. doi: 10.1016/j.tripleo.2006.01.001. Epub 2006 Apr 24. 3. Low KM, Dula K, Burgin W, von Arx T. Comparison of periapical radiography and limited cone beam tomography in posterior maxillary teeth referred for apical surgery. J Endod 2008 May;34(5):557–62. doi: 10.1016/j. joen.2008.02.022. 4. Patel S, Dawood A, Mannocci F, Wilson R, Pitt Ford T. Detection of periapical bone defects in human jaws using cone beam computed tomography and intraoral radiography. Int Endod J 2009 Jun;42(6):507–15. doi: 10.1111/j.13652591.2008.01538.x. Epub 2009 Mar 2. 5. Fayad MI, Nair M, Levin MD, Benavides E, Rubinstein RA, Barghan S, Hirschberg CS, Ruprecht A. AAE and AAOMR joint position statement — use of cone beam computed tomography in endodontics 2015 update. Oral Surg Oral Med Oral Pathol Oral Radiol 2015 Oct;120(4):508–12. doi: 10.1016/j. oooo.2015.07.033. Epub 2015 Aug 3. 6. De Paula-Silva FW, Wu MK, Leonardo MR, da Silva LA, Wesselink PR. Accuracy of periapical radiography and cone beam computed tomography scans in diagnosing apical periodontitis using histopathological findings as a gold standard. J Endod 2009 Jul;35(7):1009–12. doi: 10.1016/j. joen.2009.04.006. 7. Friedman S. Prognosis of initial endodontic therapy. Endod Topics 2002;2:59–98. 8. Patel S, Wilson R, Dawood A, Mannocci F. The detection of periapical pathosis using periapical radiography and cone beam computed tomography — part 1: Preoperative status. Int Endod J 2012 Aug;45(8):702–10. doi: 10.1111/j.13652591.2011.01989.x. Epub 2011 Dec 21. 9. Abella F, Patel S, Duran-Sindreu F, Mercad M, Bueno R, Roig M. Evaluating the periapical status of teeth with irreversible pulpitis by using cone beam computed tomography scanning and periapical radiographs. J Endod 2012 Dec;38(12):1588–91. doi: 10.1016/j.joen.2012.09.003. 10. Cheung G, Wei L, MvGrath C. Agreement between periapical radiographs and cone beam computed tomography for assessment of periapical status of root filled molar teeth. Int Endod J 2013 Oct;46(10):889–95. doi: 10.1111/ iej.12076. Epub 2013 Feb 26. 11. Sogur E, Grondahl H, Bakst G, Mert A. Does a combination of two radiographs increase accuracy in detecting acid-induced periapical lesions and does it approach the accuracy of cone beam computed tomography scanning? J Endod 2012 Feb;38(2):131–6. doi: 10.1016/j. joen.2011.10.013. Epub 2011 Dec 6. 12. Patel S, Dawood A, Mannocci F, Wilson R, Pitt Ford T. Detection of periapical bone defects in human jaws using cone beam computed tomography and intraoral radiography. Int Endod J 2009 Jun;42(6):507–15. doi: 10.1111/j.13652591.2008.01538.x. Epub 2009 Mar 2. 13. Nixdorf D, Moana-Filho E. Persistent dento-alveolar pain disorder (PDAP): Working towards a better understanding. Rev Pain 2011 Dec;5(4):18–27. doi: 10.1177/204946371100500404.

14. Pigg M, List T, Petersson K, Lindh C, Petersson A. Diagnostic yield of conventional radiographic and cone-beam computed tomographic images in patients with atypical odontalgia. Int Endod J 2011 Dec;44(12):1092–101. doi: 10.1111/j.13652591.2011.01923.x. Epub 2011 Jul 26. 15. Blattner TC, George N, Lee CC, Kumar V, Yelton CGJ. Efficacy of CBCT as a modality to accurately identify the presence of second mesiobuccal canals in maxillary first and second molars: A pilot study. J Endod 2010 May;36(5):867– 70. doi: 10.1016/j.joen.2009.12.023. Epub 2010 Feb 21. 16. Michetti J, Maret D, Mallet J-P, Diemer F. Validation of cone beam computed tomography as a tool to explore root canal anatomy. J Endod 2010 Jul;36(7):1187–90. doi: 10.1016/j. joen.2010.03.029. Epub 2010 May 13. 17. Vizzotto MB, Silveira PF, Arús NA, Montagner F, Gomes BP, Da Silveira HE. CBCT for the assessment of second mesiobuccal (MB2) canals in maxillary molar teeth: Effect of voxel size and presence of root filling. Int Endod J 2013 Sep;46(9):870–6. doi: 10.1111/iej.12075. Epub 2013 Feb 26. 18. Edlund M, Nair MK, Nair UP. Detection of vertical root fractures by using cone beam computed tomography: A clinical study. J Endod 2011 Jun;37(6):768–72. doi: 10.1016/j. joen.2011.02.034. Epub 2011 Apr 13. 19. Metska ME, Aartman IH, Wesselink PR, Özok AR. Detection of vertical root fracture in vivo in endodontically treated teeth by cone beam computed tomography scans. J Endod 2012 Oct;38(10):1344–7. doi: 10.1016/j. joen.2012.05.003. Epub 2012 Jun 30. 20. Brady E, Mannocci F, Wilson R, Brown J, Patel S. A comparison of CBCT and periapical radiography for the detection of vertical root fractures in non-endodontically treated teeth. Int Endod J 2014 Aug;47(8):735–46. doi: 10.1111/ iej.12209. Epub 2013 Dec 11. 21. Liang H, Li Gang, Wesselink P, Wu M. Endodontic outcome predictors identified with periapical radiographs and cone-beam computed tomography scans. J Endod 2011 Mar;37(3):326–31. doi: 10.1016/j.joen.2010.11.032. 22. Christiansen R, Kirkevang L-L, Gotfredsen E, Wenzel A. Periapical radiography and cone beam computed tomography for assessment of the periapical bone defect one week and 12 months after root-end resection. Dentomaxillofac Radiol 2009 Dec;38(8):531–6. doi: 10.1259/dmfr/63019695. 23. Estrela C, Bueno MR, Leles CR, Azevedo BC, Azevedo JR. Accuracy of cone beam computed tomography, panoramic and periapical radiographic for detection of apical periodontitis. J Endod 2008 Mar;34(3):273–9. doi: 10.1016/j.joen.2007.11.023. Epub 2008 Jan 31. 24.Moura MS, Guedes OA, Alencar AH, Azevedo BC, Estrela C. Influence of length of root canal obturation on apical periodontitis detected by periapical radiography and cone beam computed tomography. J Endod 2009 Jun;35(6):805– 9. doi: 10.1016/j.joen.2009.03.013. 25. Ee J, Fayad IM, Johnson BR. Comparison of endodontic diagnosis and treatment planning decisions using cone beam volumetric tomography versus periapical radiography. J Endod 2014 Jul;40(7):910–6. doi: 10.1016/j.joen.2014.03.002. Epub 2014 Apr 16. 26. Venskutonis T, Plotino G, Tocci L, Gambarini G, Maminskas J, Juodzbalys G. Periapical and Endodontic status scale based on periapical bone lesions and endodontic treatment quality evaluation using cone-beam computed tomography. J Endod 2015 Feb;41(2):190–6. doi: 10.1016/j.joen.2014.10.017. M AY 2 0 2 1

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Epub 2014 Dec 10. 27. Low KM, Dula K, Bürgin W, Arx T. Comparison of periapical radiography and limited cone beam tomography in posterior maxillary teeth referred for apical surgery. J Endod 2008 May;34(5):557–62. doi: 10.1016/j. joen.2008.02.022. 28. Tyndall D, Price J, Tetradis S, Ganz S, Hildebolt C, Scarf W. Position statement of the American Academy of Oral and Maxillofacial Radiology on selection criteria for the use of radiology in dental implantology with emphasis on cone beam computed tomography. Oral Surg Oral Med Oral Pathol Oral Radiol 2012 Jun;113(6):817–26. doi: 10.1016/j. oooo.2012.03.005. 29. May JJ, Cohenca N, Peters OA. Contemporary management of horizontal root fractures to the permanent dentition: diagnosis, radiologic assessment to include cone beam computed tomography. Pediatr Dent Mar–Apr 2013; 35(2):120–4. 30. Estrela C, Bueno MR, De Alencar AH, Mattar R, Valladares Neto J, Azevedo BC, De Araújo Estrela CR. Method to evaluate inflammatory root resorption by using cone beam computed tomography. J Endod 2009 Nov;35(11):1491–7. doi: 10.1016/j.joen.2009.08.009. 31. Durack C, Patel S, Davies J, Wilson R, Mannocci F. Diagnostic accuracy of small volume cone beam computed tomography and intraoral periapical radiography for the detection of simulated external inflammatory root resorption. Int Endod J 2011 Feb;44(2):136–47. doi: 10.1111/j.13652591.2010.01819.x. Epub 2010 Nov 17. 32. Fayad MI, Nair M, Levin MD, Benavides E, Rubinstein RA, Barghan S, Hirschberg CS, Ruprecht A. AAE and AAOMR Joint Position Statement. Use of cone beam computed tomography in endodontics — 2015/2016 update. f3f142zs0k2w1kg84k5p9i1o-wpengine.netdna-ssl. com/specialty/wp-content/uploads/sites/2/2017/06/ conebeamstatement.pdf.

Make the call that makes things better. CDA’s Well-Being Program For dental professionals who suffer from alcohol or chemical dependency, the challenges of this past year may have profound impacts on health, personal relationships and practicing safely. Volunteer members and recovering dentists offer confidential peer-to-peer support, assistance finding facilities for evaluation or treatment and guidance for family members. Visit cda.org/well-being to learn more.

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T HE CORRE S P ON DIN G AU T HOR , Rumpta Ganguly BDS, DMD, MS, can be reached at rumpta.ganguly@ucsf.edu.

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2021–2022

Visit cda.org to update your Member Profile information under My Account. Be sure your ownership status and practice details are current to benefit from a new poster set.

Transgender Rights in the Workplace

Your Rights and Obligations as a Pregnant Employee

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commentary C D A J O U R N A L , V O L 4 9 , Nº 5

Oral Health of California’s Children: A Commentary on the Status and Future Directions Jayanth Kumar, DDS MPH, and Jared Fine, DDS, MPH

AUTHORS Jayanth Kumar, DDS, MPH, is the state dental director, Office of Oral Health and the Center for Healthy Communities, California Department of Public Health. Conflict of Interest Disclosure: None reported.

Jared Fine, DDS, MPH, became dental health administrator for the Alameda County Department of Public Health in 1975, a position he held until his retirement in 2014. Conflict of Interest Disclosure: None reported.

ssessment that identifies key health needs and issues through systematic, comprehensive data collection and analysis is a key function in public health. It gives health departments, dental organizations and their partners the information to help with developing plans to achieve a community’s objective. Tooth decay is the most common chronic disease in children and often the greatest unmet need with profound disparities in the population.1 Therefore, maintaining an ongoing understanding of tooth decay prevalence, distribution in the population and the factors that influence the development of the disease is paramount to its prevention and control and in achieving the fullest potential of health for individuals. However, dentistry lacks a mechanism for routinely gathering data on disease and on oral health outcomes, constituting a major challenge for performing the key assessment function in public health. To address this, the 2012

California Dental Association Access Report recommended the establishment of a system for surveillance and oral health reporting and followed up with advocacy that resulted in significant support for oral health in the 2016 Tobacco Tax initiative.2 This among others provided the support for implementing the Association of State and Territorial Dental Directors Basic Screening Survey protocol.

Promotion of Policies, Enhancements of Programs and Improvements in the Oral Health Status of Children

In this issue of the Journal, Darsie et al. report a noticeable reduction in tooth decay experience and untreated decay and an increase in dental sealant prevalence among third grade children in public schools.3 Historically, California has had high prevalence of tooth decay. A survey of third grade children conducted in 2004–05 showed that only Arkansas had a higher prevalence of tooth decay experience than California.4 M AY 2 0 2 1

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Many initiatives undertaken since the last survey may have contributed to this improvement in oral health. Since 2007, several water systems including the Metropolitan Water District of Southern California began providing fluoridated water, resulting in 59.3% of the population receiving fluoridated water, up from 27.1%.5 The percentage of children under age 21 who were enrolled in the Medi-Cal Dental Program and received a dental service increased to 46% in 2019 from 28% in 2006.6 In addition, the following policies and system-level changes also occurred during this timeframe: ■ Implementation of the Affordable Care Act (ACA), which increased dental insurance benefit coverage, affordability and integration. ■ Implementation of the kindergarten oral health assessment as part of school entrance requirements. ■ Promotion of screening, fluoride varnish and anticipatory guidance during well-child visits by the American Academy of Pediatrics and the age 1 dental visit. ■ The California Dental Association Foundation’s 2010 Oral Health During Pregnancy and Early Childhood: Evidence‑Based Guidelines for Health Professionals and training of dental professionals to provide dental care for children under 6 years old. ■ The restoration of adult dental benefits, which may have increased utilization for children and youths as well as adults. ■ The Medi-Cal Dental Program’s implementation of the recommendations of the Little Hoover Commission, including the 2015 Medicaid Dental Transformation Initiative and supplemental payments to increase preventive dental visits. 328 M AY

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■

The Medi-Cal Dental Program’s “Smile, California” campaign to increase members’ use of Medi-Cal’s dental benefit.

Disparities in Oral Health and Opportunities for Improvement

Darsie et al. also report that the prevalence of tooth decay remains high, and there are profound disparities with respect to race/ethnicity, socioeconomic status, languages spoken and geography. While there is no noticeable racial/ ethnicity or socioeconomic disparities

The percentage of children under age 21 who were enrolled in the Medi-Cal Dental Program and received a dental service increased to 46% in 2019 from 28% in 2006. with respect to sealants, the prevalence varied from a low of 29% in the Sacramento region to a high of 47% on the Central Coast. Overall, the prevalence remains low when compared to national data observed among children aged 9–11 years examined in the National Health and Nutrition Examination 2011– 2016 Survey (37.0% versus 50.7%).1 This observation, together with the profound disparities of tooth decay, suggests missed opportunities for prevention in younger children. Therefore, more efforts are needed to improve daily mouth care at home, provide community-level interventions and facilitate early dental visits. A concerted effort is required to promote healthy habits such as toothbrushing with a fluoride toothpaste and reducing sugar intake, timely dental

visits starting early in a child’s life, access to professionally applied topical fluoride applications (e.g., in dental and nondental settings), community-level interventions such as water fluoridation and community-clinical linkages and improving oral health literacy. California is poised to make significant improvements by implementing the strategies identified in the California Oral Health Plan 2018–2028.7 First, California has set an ambitious target for third grade children to reduce the prevalence of caries from 70.6% in 2004–05 to 56.5% by 2025. Second, using the funding provided through the 2016 California Healthcare, Research and Prevention Tobacco Tax Act, the California Department of Public Health (CDPH) has established a statewide program with a focus on preventing tooth decay in children. It is providing $18 million annually across 59 local health jurisdictions to conduct local level, county-specific needs assessments, develop a community oral health improvement plan and implement interventions. Third, the Medi-Cal Dental Program is working collaboratively with public health programs and stakeholders to increase access to dental care. Fourth, CDPH is working to increase access to community water fluoridation (CWF) through maintaining and expanding state, local and tribal community water fluoridation programs. CDPH is encouraging compliance with proper water fluoridation practices through the promotion of CDC training and technical assistance resources. Fifth, CDPH is working with local oral health programs (LOHPs) to develop communitybased programs such as school-based/ linked programs to connect children in community settings to a source of dental care. Sixth, the kindergarten oral health assessment, required in California, helps identify children suffering from dental

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disease and assists them in finding a dental home. LOHPs are offering assistance in implementing kindergarten dental assessment protocols, track progress and improve the performance of and compliance with the kindergarten dental assessment. Finally, the Office of Oral Health has contracted with the Health Research for Action Center, University of California, Berkeley, to create materials for an oral health literacy toolkit and conduct trainings for dental teams and practices to improve the uptake of information about oral health literacy. The toolkit will include information on specific communication strategies, including plain language communication, the use of visuals and drawings, the teach-back method and creating a friendly and welcoming clinical environment. In addition, the California Oral Health Technical Assistance Center at the University of California, San Francisco, has created resources for local health departments and dental practitioners to promote the kindergarten oral health assessment, water fluoridation, school-based/linked programs and tobacco cessation counseling.8

Role of Dental Practitioners

At the local level, there are many opportunities for individual practitioners and component dental societies to advance the partnerships that increase awareness about oral health, provide early strategies to prevent dental caries and expand access to care. The annual “Give Kids a Smile” program can serve as a focal point for components focused on an educational campaign with local schools. An example could be reducing sugar sweetened beverage (SSB) consumption and increasing water choices through the “Rethink Your Drink” or “Soda-Free Summer” campaigns.9 Partnering with schools is also an opportunity to foster

their participation in the Kindergarten Oral Health Assessment (KOHA) in which practitioners can develop partnerships with schools to offer screening and encourage fluoride, sealants and early dental visits for those who have not done so. To fulfill the federal mandate that every eligible child have a complete “well-child visit,” which includes a dental examination, every county has a Child Health and Disability Prevention Program (CHDP) required to maintain an adequate dental provider referral resource list. Each component could

Because the majority of the CHDP service population is under age 5, fluoride varnish applications are appropriate and should be promoted. easily include in their bulletins reminders encouraging members to participate in these annual surveys. In addition, each LOHP is required to maintain an advisory committee, offering another opportunity for individual practitioners to participate in guiding oral health improvement efforts at the local level.

Role of Local Oral Health Programs

LOHPs have a responsibility to develop the plans and linkage to care systems, implement programs and services that are prevention focused and promote improved oral health outcomes. By partnering with the CHDP program in each county and with First 5 organizations, LOHPs can play a pivotal role in the training and education of medical providers (e.g., pediatricians and

family practitioners) who perform wellchild and periodic health assessments as well as educate and inform the public. Because the majority of the CHDP service population is under age 5, fluoride varnish applications are appropriate and should be promoted. The CHDP program is perfectly situated to provide oral health educational materials in offices encouraging health-promoting diets, increased tap water consumption over SSBs, dental visits by age 1 and KOHAs and facilitating presentations of early childhood caries and fluoride varnish at pediatric grand rounds at local hospitals and at CHDP provider meetings. The CHDP program requires that every child be referred for a dental examination and has the capacity to provide care coordination either directly or with partners to ensure that children are not only referred but also able to successfully access dental care. The LOHPs can also identify gaps in service based on distance, language or capacity to provide services and foster recruitment efforts with the Medi-Cal Dental Program and through partnership with the local dental society. Many local-level stakeholders embrace the importance of assuring the oral health of children and are natural partners: notably, Head Start, the Women, Infants and Children Nutrition Supplementation Program (WIC) and elementary schools. Both Head Start and Early Head Start require that a participating child have a dental examination, creating an opportunity to offer both education and preventive services. Head Start parent advocates can serve the natural role of education and care coordination as well. The WIC program is designed to provide not only food vouchers, but also dietary education and counseling. Because caregivers are in attendance with young children, the opportunity to influence mouth-healthy practices is M AY 2 0 2 1

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particularly rich. For example, many WIC programs have welcomed the LOHP’s assistance in offering staff training on early childhood caries (ECC), individual and group education, individual oral health assessments, one-on-one oral hygiene instruction, fluoride varnish application, caries risk assessment and referral to a dentist in the community. Unlike WIC, schools do not have the advantage of caregivers in attendance. However, schools are where most children are congregated. Schools are the gatekeeper to screenings, the KOHA, sealant application or fluoride varnish programs. As such, schools should be promoting healthy eating policies and practices and increased water consumption and discouraging soda consumption through enactment of policies and educational campaigns.10 Churches, boys and girls clubs and community health centers are additional examples of natural partners that share the goal of optimal oral health for children and represent a significant opportunity to intervene with educational campaigns, care coordination and the promotion and delivery of early preventive interventions.

Conclusions

In spite of noticeable improvements in the oral health of children in California, tooth decay remains a major public health problem. The COVID-19 pandemic has affected the delivery of dental services and disproportionately impacted certain disadvantaged groups. The state governmental programs, local health jurisdictions, professional organizations and advocacy groups have affirmed their commitment to improving the oral health of Californians. We encourage you to review the data and share your expertise and perspective to move forward the state’s oral health agenda. n 330 M AY

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RE FE RE N CE S 1. Centers for Disease Control and Prevention. Oral Health Surveillance Report: Trends in Dental Caries and Sealants, Tooth Retention and Edentulism, United States, 1999–2004 to 2011–2016. www.cdc.gov/oralhealth/publications/OHSR2019-index.html. 2. California Dental Association. Phased Strategies for Reducing the Barriers to Dental Care in California, California Dental Association Access Report. www.cda.org/Portals/0/ pdfs/access_to_care/access-report.pdf. 3. Darsie B, Conroy S, Kumar J. California Smile Report. J Calif Dent Assoc 2021 May;49(5):331–336. 4. Dental Health Foundation. Mommy It Hurts to Chew: The California Smile Survey. www.centerfororalhealth.org/ wp-content/uploads/2018/11/Mommy-It-Hurts-To-Chew. compressed.pdf. 5. Centers for Disease Control and Prevention. Water Fluoridation Data and Statistics. www.cdc.gov/fluoridation/ statistics/index.htm. 6. Centers for Medicare and Medicaid Services. Early and Periodic Screening, Diagnostic and Treatment. www.medicaid. gov/medicaid/benefits/early-and-periodic-screeningdiagnostic-and-treatment/index.html. 7. California Department of Public Health. California Oral Health Plan 2018–2028. 8. California Oral Health Technical Assistance Center. University of California San Francisco. oralhealthsupport.ucsf. edu. 9. California Department of Public Health. Nutrition Education and Obesity Prevention Branch: Rethink Your Drink. www. cdph.ca.gov/Programs/CCDPHP/DCDIC/NEOPB/Pages/ RethinkYourDrink.aspx. 10. California Oral Health Technical Assistance Center. School Oral Health Programs. oralhealthsupport.ucsf.edu/ our-programs/school-programs. T H E CO RRE S P ON DIN G AU T HOR , Jayanth Kumar, DDS, MPH, can be reached at Jayanth.Kumar@cdph.ca.gov.

oral health briefing C D A J O U R N A L , V O L 4 9 , Nº 5

Oral Health Status of Children: Results of the 2018–2019 California Third Grade Smile Survey Brendan Darsie, MPH; Shannon Conroy, PhD, MPH; and Jayanth Kumar, DDS, MPH

abstract This report presents findings from a survey of third grade children conducted during the 2018 and 2019 school years. The prevalence of tooth decay, untreated tooth decay and dental sealants was 61%, 22% and 37%, respectively. Overall achievements among third graders included a noticeable reduction in tooth decay experience (61% down from 71%) and untreated decay (22% down from 29%) and an increase in dental sealant prevalence (37% up from 28%) compared to the 2004–05 school year when this was last assessed. However, tooth decay remains a significant public health problem, especially among certain racial/ethnic and socioeconomically disadvantaged groups.

AUTHORS Brendan Darsie, MPH, is a research scientist II for the Office of Oral Health and the Center for Healthy Communities in the California Department of Public Health. Conflict of Interest Disclosure: None reported.

Shannon Conroy, PhD, MPH, is a research scientist supervisor I and the chief of the Surveillance and Evaluation Unit for the Office of Oral Health and the Center for Healthy Communities in the California Department of Public Health. Conflict of Interest Disclosure: None reported. Jayanth Kumar, DDS, MPH, is the state dental director, Office of Oral Health and the Center for Healthy Communities, California Department of Public Health. Conflict of Interest Disclosure: None reported.

n 2014, the California Legislature set forth a vision to assess and improve oral health in the state.1 A 2017 report, the Status of Oral Health in California: Oral Disease Burden and Prevention, found the state was not on track to achieve many of the Healthy People 2020 national goals and objectives.2 The report determined that California ranked in the lower quartile among states in children’s oral health status and receipt of preventive dental services. There were marked oral health disparities with respect to race and ethnicity and income and education, but the data were not current. Ongoing monitoring of state-specific oral health outcomes along with continual assessment and evaluation are needed to support policies and programs. To fulfill this function, the Association of State and

Territorial Dental Directors developed the Basic Screening Survey protocol.3 The last such survey in California was conducted among kindergarten and third grade children in the 2004–2005 school year.4 This report presents key findings from the California Smile Survey (CSS), a population-based, representative survey of 12,562 third grade children conducted during the 2018–2019 and 2019–2020 school years (TA BLE 1 ). The results are compared to a similar CSS conducted during the 2004–2005 school year.

Methodology

The CSS was administered during the 2018–2019 and 2019–2020 school years to a representative sample of third grade children in California. The sampling methodology was a stratified M AY 2 0 2 1

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TABLE 1

Characteristics of the 2018–2019 California Third Grade Smile Survey Sample and the Weighted Percentage Category

Number

Percentage (weighted)

African American

705

5.3%

Asian/Pacific Islander

1,196

9.2%

Race/ethnicity

Hispanic/Latino

7,400

54.9%

White

2,083

22.2%

Other

823

7.4%

No race/ethnicity cited

115

1.0%

Gender Female

6,039

49.0%

Male

6,283

51.0%

English learner

3,627

24.7%

English proficient

8,695

75.4%

6,917

61.2%

English learners a

Parent primary language English Spanish

4,247

29.6%

Other

1,158

9.2%

Migrant Program: Yes

143

1.1%

Migrant Program: No

1,2179

98.9%

Migrant program status b

Special education c Special Education Program: Yes

1,457

11.9%

Special Education Program: No

10,865

88.1%

Socioeconomic index Socioeconomically disadvantaged d

8,407

61.9%

Not Socioeconomically disadvantaged

3,915

38.1%

a. English-learner students are those students for whom there is a report of a primary language other than English on the state-approved Home Language Survey and who, on the basis of the state-approved oral language (kindergarten through grade 12) assessment procedures and literacy (grades three through 12 only), have been determined to lack the clearly defined English language skills of listening comprehension, speaking, reading and writing necessary to succeed in the school’s regular instructional programs. b. The Migrant Education Program is designed to support high-quality and comprehensive educational programs for migrant children to help reduce the educational disruption and other issues that result from repeated moves. c. Special education is specially designed instruction to meet the unique needs of a child with a disability. d. Socioeconomically disadvantaged is defined as children who were migrant, foster or homeless, were eligible for the free or reduced-price meal program or whose parents have not graduated from high school.

random sample of clusters of children from public schools with 25 or more third grade students. The sample was selected to represent California’s third grade public school population based on eight geographic regions across the state and a 332 M AY

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representative distribution of schools based on the percentage of children eligible for free or reduced-price meals within each region, using implicit stratification. The regions were utilized to ensure geographic strata representation across the state.

There were not separate selections for each region. Out of 223 schools selected for the sample, 194 participated and a total of 12,562 children were screened. Every third grade student present in the selected schools was screened unless they opted out. Passive consent was the preferred method, as there is an existing oral health screening law in California allowing passive consent for children in kindergarten. However, 18.2% of the participants were screened at schools that required positive consent. The overall participation rate was 71.3% among children at schools that were screened. The participation rate for children at schools requiring positive consent and schools permitting passive consent was 56.0% and 75.1%, respectively. The CSS assessed participating children for tooth decay experience, untreated tooth decay and dental sealant prevalence. Additional participant information was provided by the California Department of Education (CDE), including the child’s race/ethnicity, socioeconomic disadvantage and the parent’s primary language. The California Department of Public Health (CDPH) examined the socioeconomic disparities in children’s oral health using the CDE’s Socioeconomically Disadvantaged Index (SED). The following categories were used to determine socioeconomic disadvantage: children who were eligible for the National School Lunch Program at any time during the academic year; being a migrant, a foster child or homeless at any time during the academic year; or having parents who did not receive a high school diploma (or equivalent). Registered dental hygienists administered the CSS according to the Association of State and Territorial Dental Directors’ Basic Screening Survey protocol. The examiners were trained in conducting the dental screenings.3 During the training, examiners would pair up and screen the same children,

C D A J O U R N A L , V O L 4 9 , Nº 5

TABLE 2

Percentage (95% CI) of Third Grade Children With Caries Experience, Untreated Tooth Decay and Dental Sealants by Selected Characteristics: 2018–2019 California Third Grade Smile Survey

but no replicate examinations were done after the training. The dental measures gathered from the assessment were caries experience, untreated decay and dental sealants (only on permanent molars). The socioeconomic data was obtained through a data linkage agreement with the CDE. The CDPH used the geographic strata and the CDE socioeconomic disadvantage index in the creation of raking weights to ensure that the statistics generated from the data were representative of the target population.5 Only participants not missing data on the socioeconomic disadvantage index were included in the analysis resulting in a final sample size of 12,322 children. All statistical analyses were performed using SAS complex survey procedures (Version 9.4; SAS Institute Inc., Cary, N.C.), but raking weights were created using R (R Foundation for Statistical Computing, Vienna, Austria).

Findings

Key finding 1: Tooth decay remains a significant public health problem. However, an overall noticeable reduction in tooth decay experience and untreated decay and an increase in dental sealant prevalence have been achieved. In California, tooth decay remains a significant public health problem. By the third grade, 6 in 10 children (61%) have experienced tooth decay and 1 in 5 children (22%) have untreated tooth decay (TA BLE 2). The prevalence of tooth decay and untreated decay was lower in 2018–2019 compared to the mid-2000s (FIGURE 1), representing an 10-percentage point decrease in tooth decay and a 7-percentage point decrease in untreated decay. Additionally, more children are benefiting from dental sealants (37%), which is an 8-percentage point increase from the mid-2000s. Among California children, improvements in oral health are evident

Category

Caries experience (95% confidence interval)

Untreated decay (95% confidence interval)

Sealants (95% confidence interval)

All of California

60.6% (57.7–63.5)

21.9% (20.2–23.6)

37.0% (34.7–39.3)

Race/ethnicity African American

59.1% (54.3–63.9)

25.8% (20.9–30.8)

32.9% (26.8–39.0)

Asian/Pacific Islander

50.2% (45.1–55.2)

17.4% (13.9–20.9)

38.4% (32.5–44.4)

Hispanic/Latino

72.2% (69.8–74.6)

24.8% (22.8–26.7)

35.8% (33.4–38.2)

White

40.0% (35.8–44.2)

13.7% (11.2–16.3)

39.8% (35.1–44.4)

Other

50.6% (45.3–55.9)

18.2% (14.4–22.0)

38.7% (34.0–43.3)

No race/ethnicity cited

52.6% (41.1–64.1)

19.3% (11.5–27.1)

42.8% (31.1–54.6)

Female

60.3% (57.0–63.5)

22.4% (20.3–24.6)

36.8% (34.3–39.2)

Male

60.9% (57.8–64.0)

20.0% (18.0–22.0)

37.3% (34.8–39.8)

English learner

76.0% (73.5–78.4)

26.8% (24.3–29.3)

36.5% (32.9–40.1)

English proficient

54.7% (51.6–57.8)

19.0% (17.2–21.0)

37.2% (34.7–39.8)

English

52.2% (49.1–55.4)

18.4% (16.5–20.3)

37.0% (34.2–39.8)

Spanish

77.9% (75.7–80.0)

26.3% (23.9–28.7)

35.9% (33.0–38.7)

Other

55.3% (50.1–60.4)

21.8% (17.8–25.8)

41.0% (34.8–47.3)

Migrant program: Yes

76.3% (67.8–84.9)

31.1% (23.7–38.6)

40.2% (28.0–52.5)

Migrant program: No

60.4% (57.4–63.4)

21.1% (19.3–22.9)

37.0% (34.7–39.3)

Special education program: Yes

62.1% (58.8–65.5)

20.9% (18.2–23.5)

35.4% (32.1–38.7)

Special education program: No

60.4% (57.4–63.4)

21.2% (19.3–23.1)

37.2% (34.9–39.6)

Socioeconomically disadvantaged

72.8% (70.9–74.7)

26.0% (24.0–28.1)

35.9% (33.5–38.2)

Not socioeconomically disadvantaged

40.5% (37.3–43.8)

13.2% (11.4–15.0)

38.9% (35.2–42.6)

Gender

English learners

Parent primary language

Migrant program status

Special education

Socioeconomic index

in tooth decay and application of sealants; however, California third graders have a substantially higher proportion of tooth decay compared to the national median of 53% among states.6 The California Oral Health Plan 2018–2028 set targets for tooth decay, untreated decay and sealant prevalence in third grade children.1 While the results of the CSS show that

California has met its goals for prevalence of untreated decay and use of sealants, the state has work to do to meet the goal for the reduction of tooth decay. Key finding 2: Disparities by race/ethnicity and socioeconomic disadvantage for tooth decay and untreated decay are profound. M AY 2 0 2 1

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oral health briefing C D A J O U R N A L , V O L 4 9 , Nº 5

80 70

Percent

60 50 40 30 20 10 0

Caries experience

Untreated decay

2004 – 2005

Dental sealants

2018 – 2019

2025 target

FIGURE 1. Percentage of third grade children with caries experience, untreated tooth decay and dental sealants, 2004–05 and 2018–2019 California Third Grade Smile Surveys.

While it is encouraging to observe improvements in tooth decay, untreated decay and dental sealant prevalence, significant disparities still exist (TA BLE 2 ). Latinx children had the highest prevalence of tooth decay, with more than 72% having experienced some form of tooth decay compared to 40% of white children (FIGURE 2 ). African American children had the highest prevalence of untreated decay at 25.8%, which is almost twice the rate of white children at 13.7%. Socioeconomically disadvantaged children had almost twice the rate of tooth decay and untreated tooth

decay compared to children who were not socioeconomically disadvantaged (tooth decay 72.3% versus 40.5%; untreated tooth decay 26% versus 13.2%). Children from families whose parents’ primary language is Spanish were more likely to have experienced tooth decay (77.9% versus 52.2% for English language) or to have untreated decay (26.3% versus 18.4% for English language). Key finding 3: Dental sealant prevalence, a reflection of the use of preventive services, was low. However,

80 70

Percent

60 50 40 30 20 10 0

Caries experience

African-American

Asian/Pacific Islander

White

Other

2025 target

FIGURE 2 . Percentage of third grade children with caries experience and untreated tooth decay by race/ ethnicity, 2018–2019 California Third Grade Smile Survey.

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Key finding 4: Regional variation in children’s oral health exists across California. The oral health status of children varied by region (TA BLE 3 ). Children from the San Joaquin Valley had the highest prevalence of tooth decay (75.9%) and untreated decay (29.7%). However, the Sacramento region had the lowest prevalence of dental sealants (28.9%). While the Central Coast region had higher levels of tooth decay (64.2%), the proportion of children with untreated disease was lower (16.3%) and sealant prevalence was higher (46.8%). Overall, the Bay Area region had the most favorable outcomes: prevalence of tooth decay, untreated tooth decay and sealants was 45.4%, 15.7% and 44.6%, respectively.

Limitations

Untreated decay Latinx

disparities with respect to dental sealant prevalence were not observed. The prevalence of dental sealants was low compared to national data observed among children aged 9–11 years examined in the National Health and Nutrition Examination 2011–2016 Survey (34.0% versus 50.7%).7 This difference may be due in part to the fact that some 9- to 11-year-old children are older than the average third grader and would therefore have more opportunity to receive sealants. However, the prevalence was similar across race/ethnicity and income subpopulations. (FIGURE 3 ). This suggests similarities in access to preventive services for school-aged children across all population groups.

First, the Basic Screening Survey (BSS) methodology is meant to be used for surveillance of children’s oral health, and therefore a comprehensive oral examination to determine severity of the disease is not possible. Second, the

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TABLE 3

Percentage of Third Grade Children With Caries Experience, Untreated Tooth Decay and Dental Sealants by Region: 2018–2019 California Third Grade Smile Survey TABLE 3 Region

Sample size

Caries experience

Untreated decay

Sealants

Bay Area

1,188

45.4% (35.7–55.2)

15.7% (9.4–22.1)

44.6% (37.7–51.6)

Central Coast

749

64.2% (53.2–75.1)

16.3% (11.3–21.4)

46.8% (36.5–57.1)

Los Angeles County

4,580

64.7% (60.1–69.4)

20.7% (18.7–23.2)

30.5% (27.5–33.4)

Northern/Sierra

255

51.6% (36.6–66.7)

20.7% (8.9–32.6)

36.5% (27.8–45.2)

Sacramento Region

639

46.2% (36.9–55.4)

17.2% (10.1–24.3)

28.9% (22.0–35.8)

San Joaquin Valley

1,939

75.9% (70.8–80.9)

29.7% (25.8–33.5)

33.2% (28.7–37.6)

Southern

2,972

60.4% (54.6–66.2)

21.8% (18.5–25.1)

40.0% (35.0–45.1)

Note: 95% confidence interval is provided in parentheses. County regional grouping: • Bay Area (9): Santa Clara, Contra Costa, Alameda, San Francisco, San Mateo, Sonoma, Solano, Marin, Napa • Central Coast (6): Ventura, Santa Barbara, Santa Cruz, San Luis Obispo, Monterey, San Benito • Los Angeles (1): Los Angeles County (two sampling regions were pulled from Los Angeles County alone, but the decision was made to display rates for the entirety of Los Angeles County) • Northern/Sierra (25): Butte, Humboldt, Mendocino, Tehama, Glenn, Colusa, Yuba, Tuolumne, Calaveras, Amador, Inyo, Mariposa, Mono, Alpine, Shasta, Del Norte, Siskiyou, Lassen, Trinity, Modoc, Plumas, Sierra, Lake, Sutter, Nevada • Sacramento Region (4): Sacramento, Placer, Yolo, El Dorado • San Joaquin Valley (8): Fresno, Kern, San Joaquin, Stanislaus, Tulare, Merced, Kings, Madera • Southern (5): Orange, San Diego, San Bernardino, Riverside, Imperial

sample size did not allow for estimation of the outcomes for each individual county or certain subgroups (e.g., homeless children). Third, these data are only available for children in public schools and public charter schools, not for children outside of the public school system. Fourth, it is possible there were inconsistencies in how different hygienists recorded the data. To minimize this, the same trainer calibrated the screening and standardized the data collection by each dental hygienist gathering the oral health data. Finally, certain parents and schools were reticent to provide the data necessary to complete the data linkage. It is possible the missing data caused by this reticence is not random and the estimates generated are therefore biased in some way. However, the overall participation rate was still quite high, and the creation of the raking weights would have accounted for some of the potential bias. n D E FI NI TIO NS Dental caries experience: Caries experience means that a child has had tooth decay at some point in time. Caries experience covers both past treatment (e.g., fillings, crowns) and untreated decay at the present time (e.g., untreated cavities). Untreated tooth decay: Untreated decay is tooth decay (e.g., one or more cavities) that has not received treatment.

California Overall 2025 Target Race/Ethnicity African American Asian/Pacific Islander Latinx White Other Socioeconomic Index Socioeconomically Disadvantaged Not Socioeconomically Disadvantaged Parent Primary Language English Spanish Other 0%

10% 15% 20% 25% 30% 35% 40% 45% 50%

Percent FIGURE 3 . Dental sealant prevalence in third grade children by race/ethnicity, socioeconomic index and parent

primary language percent.

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oral health briefing C D A J O U R N A L , V O L 4 9 , Nº 5

Dental sealants: Dental sealants are plastic-like coatings that are applied to the chewing surfaces of teeth. The applied sealant protects the teeth from decay. AC KN OW LEDGM EN TS CDPH thanks the following organizations and individuals who were instrumental in the completion of the CSS: California Department of Education, Los Angeles Department of Public Health, California State University, Sacramento’s Public Health Survey Research Group, University of California, Los Angeles, School of Dentistry and Dr. Kathy Phipps from the Association of State and Territorial Dental Directors. CDPH also sincerely thanks the participating schools and dental hygienists who conducted the screenings. RE FEREN CE S 1. Kumar J, Jackson R. (2018). California Oral Health Plan 2018-2028. California Department of Public Health: Sacramento, Calif. www.cdph.ca.gov/Programs/CCDPHP/ DCDIC/CDCB/CDPH%20Document%20Library/Oral%20 Health%20Program/FINAL%20REDESIGNED%20COHP-OralHealth-Plan-ADA.pdf.

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2. Status of Oral Health in California: Oral Disease Burden and Prevention 2017. California Department of Public Health. www.cdph.ca.gov/Programs/CCDPHP/DCDIC/CDCB/ CDPH%20Document%20Library/Oral%20Health%20 Program/Status%20of%20Oral%20Health%20in%20 California_FINAL_04.20.2017_ADA.pdf. 3. Association of State and Territorial Dental Directors. Basic Screening Survey Tool. www.astdd.org/basic-screeningsurvey-tool Accessed Oct. 01, 2020. More information at www.cda.org/Portals/0/pdfs/access_to_care/access-report. pdf. 4. Dental Health Foundation. “Mommy, It Hurts to Chew” The California Smile Survey: An Oral Health Assessment of California’s Kindergarten and 3rd Grade Children. Oakland, CA, 2006. www.astdd.org/docs/ca-third-gradebss-2006.pdf or www.centerfororalhealth.org/wp-content/ uploads/2018/11/Mommy-It-Hurts-To-Chew.compressed.pdf. 5. Wang Y, et al. 2020. Enhancing sampling weights using raking method. In JSM Proceedings, Survey Research Methods Section. American Statistical Association, 202:136–143. www.researchgate.net/profile/Yan-Wang-261/ publication/347422831_Enhancing_Sampling_Weights_

2021

LDM_CDA_Journal_1.3_Square_LindaBrown_05_23_17.indd 1

5/24/2017 9:21:40 PM

Using_Raking_Method/links/5fdb10bfa6fdccdcb8d1cbd9/ Enhancing-Sampling-Weights-Using-Raking-Method.pdf. 6. Centers for Disease Control and Prevention. Oral Health Data. nccd.cdc.gov/oralhealthdata/rdPage. aspx?rdReport=DOH_DATA.ExploreByTopic&islYear=2016 %E2%80%932017&islTopic=CHD&go=GO. Accessed Feb. 1, 2021. 7. Centers for Disease Control and Prevention. Oral Health Surveillance Report: Trends in Dental Caries and Sealants, Tooth Retention and Edentulism, United States 1999–2004 to 2011–2016. www.cdc.gov/oralhealth/publications/OHSR2019-index.html. T HE CORRE S P ON DIN G AU T HOR , Jayanth Kumar, DDS, MPH, can be reached at jayanth.kumar@cdph.ca.gov.

interprofessional education C D A J O U R N A L , V O L 4 9 , Nº 5

Development of an Interprofessional Education Event To Improve Dental and Pharmacy Students’ Attitudes Toward Interprofessional Collaboration Erin Richards, DDS; Paul Gavaza, PhD; Farnoosh Zough, PharmD, BCPS; Jennifer Mathew, MA; and Alireza Hayatshahi, PharmD, BCPS

abstract This study assessed 119 second-year pharmacy and dental students’ knowledge and attitudes toward interprofessional collaboration (IPC) before and after a two-hour curricular event held in May 2017. The event was associated with a significant improvement in the students’ attitudes toward IPC on six of the 21 items assessed (p < 0.05). Pharmacy students had significantly different mean attitude scores than dental students on 18 of the 21 IPC-related items assessed (p < 0.05). This interprofessional event (IPE) allowed for collaboration between dental and pharmacy students and faculty and improved students’ acceptance of and attitudes toward IPC. Key words: Pharmacy, health professions education, interprofessional teamwork, interprofessional learning, interprofessional education

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interprofessional education C D A J O U R N A L , V O L 4 9 , Nº 5

AUTHORS Alireza Hayatshahi, PharmD, BCPS, is the chair and associate professor of pharmacy practice at the Loma Linda University School of Pharmacy and an associate professor in dental education services in the Loma Linda University School of Dentistry. Conflict of Interest Disclosure: None reported. Erin Richards, DDS, is an associate professor at the Loma Linda University School of Dentistry and an assistant professor of pharmacy practice at the Loma Linda University School of Pharmacy. Conflict of Interest Disclosure: None reported. Paul Gavaza, PhD, MS, MSc, is as an associate professor of pharmaceutical and administrative sciences at the Loma Linda University School of Pharmacy. Conflict of Interest Disclosure: None reported.

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Farnoosh Zough, PharmD, BCPS, is the director of introductory pharmacy practice experience and an associate professor of pharmacy practice at the Loma Linda University School of Pharmacy. Conflict of Interest Disclosure: None reported. Jennifer Mathew, MA, is the director of alumni affairs and communications at the Loma Linda University School of Pharmacy. Conflict of Interest Disclosure: None reported.

mproved patient safety, quality of patient care, improved health of populations and reduced per capita cost of health care1–3 are important goals of health care. To achieve these goals requires that different health professionals work together in caring for their patients.3 Pharmacy-dentistry collaborations have led to improved medication documentation and evaluation, less errors for taking medication history, reduced medication discrepancies, fewer opioid prescriptions and greater patient knowledge and intentions to use medications for tobacco cessation1,4,5 among others. The collaboration between professionals may take many different forms in practice including the integration of pharmacists in dental clinics.1,2,4–9 Collaborative practice is best learned or introduced in professional training in the form of interprofessional education (IPE). IPE is “when students from two or more health care professions learn about, from and with each other to enable effective collaboration and improve health outcomes.”3 IPE prepares health professions students to work collaboratively when they graduate. The Commission on Dental Accreditation (CODA) and the Accreditation Council for Pharmacy Education (ACPE) now require dental and pharmacy schools respectively to incorporate IPE within their curriculum.10,11 It is crucial to introduce the concept of learning with other future colleagues early on in the curriculum to help shape their newly developing perspectives on clinical teamwork.12 However, little is known about efforts to incorporate IPE in pharmacy and dental education. IPE training in pharmacy and dental education primarily consists of clinical experiences, didactic training (e.g., in-class sessions and online lectures) or both. Clinical experience

is mainly comprised of pharmacy or dental students collaborating within pharmacies or dental clinic settings.1,4–8 Some schools and colleges such as the Midwestern University Colleges of Pharmacy and Dental Medicine have developed a comprehensive elective IPE course with a didactic portion designed to improve pharmacy and dental students’ knowledge of pharmacotherapy for dental conditions6 and practice experience components (e.g., clinic sessions).6 IPE initiatives and events improve pharmacy and dental students’ knowledge about the scope of practice of other health care professions and improve their attitudes toward interprofessional collaboration (IPC). IPE initiatives help students understand different ways that pharmacists can contribute to dental practice including taking medication histories, providing medication management, providing patient counseling for medication adherence issues, addressing concerns regarding information about illness, identifying drug-related problems such as adverse drug reactions or drug interactions, understanding dental implications of medication and offering recommendations for prescribed medications.1,5–8 There are barriers to IPE and IPC including the dental and pharmacy faculty’s and students’ lack of knowledge and understanding of the roles of the other health care profession, schedule limitations for dental and pharmacy students and faculty, logistical difficulties such as the interference with routine workflow of the dental clinic, limited access to patients, limited administrative support, lack of collaborators and champions within the institution and students’ lack of openness toward IPE and lack of acceptance of an interprofessional role.1,9,13 Another important barrier to these concepts is administrative,

C D A J O U R N A L , V O L 4 9 , Nº 5

TABLE 1

Characteristics of Students and Courses

faculty and student attitudes in this regard because it is foundational to the initial yet necessary cultural shift in perception of health care education. Since 2010, Loma Linda University has embraced the principles of IPE and taken measures to incorporate a shared learning approach in its teaching methods. The vision of the University’s Center for Interprofessional Education (CIPE) is, “To train students in a way to work and communicate with other health care professionals in an environment of mutual respect and values, using their knowledge and experience to provide a team-based approach and patient-centered care.” An example of an IPE activity held at Loma Linda University is the annual Critical Event/Disaster Response (CER) course that is taken by all graduating medical, pharmacy, allied health and nursing students.14 This four-hour interdisciplinary course includes critical-event response and IPE competencies, features highfidelity medical simulations and provides students with hands-on decontamination modules and a mass-casualty triage.14 This study reports on an IPE event that was designed to improve second-year pharmacy and dental students’ knowledge, attitudes and acceptance of IPE and IPC.

Materials and Methods

Faculty from the Loma Linda University School of Pharmacy and School of Dentistry responsible for teaching two second-year dentistry and pharmacy didactic therapeutic courses collaborated to design a two-hour curricular session held in May 2017. This IPE satisfied the Accreditation Council for Pharmacy Education (ACPE) and CODA requirements.10,11 Faculty from both schools created patient cases and summary questions that incorporated content from lecture material from both courses. The cases and questions asked of students were designed to encourage discussion on the management

Item

Dental students

Pharmacy students

Course name

PHRM 501 Pharmacology and Therapeutics

RXTH 570 Introduction to Disease Management

Number of course units (quarter hours)

4.0

2.5

Percent of course grade accounted for by IPE session

5% of overall course grade

2% of overall course grade

Academic year/term

Spring quarter of the second year

Number of students registered in the courses

50 (55%) 41 (45%)

28 (39%) 44 (61%)

79 (66.4%)

40 (33.6%)

Gender: number (%) Male Female Matched data (pre- and postsurveys, n = 119)

of adverse drug events and preventable drug-drug and drug-disease interactions. All second-year dental and pharmacy students registered in the two required courses were required to participate in the IPE event. The content from the discussion of the patient cases was included on the final exams for both the pharmacy and dentistry courses. During the event, the students were assigned to 25 groups each comprising on average two pharmacy students and four dental students. Students were instructed to work collaboratively to assess each of their five assigned patient cases. Dental and pharmacy faculty observed and facilitated student interactions and deliberations. Following the group discussions, each group was asked to answer a question pertaining to the patient case when all of the other groups were listening. Group members chose one student to represent their group to respond to questions posed to their group during the open forum. The Q&A session helped the faculty to assess the depth of students’ understanding of the patient cases and provided faculty facilitators the opportunity to further clarify and explain the rationale of the therapeutics and treatment modifications. The Readiness for Interprofessional Learning Scale (RIPLS) was used to assess students’ attitudes toward interprofessional education and collaboration a day before

and two days after the event. The online pre- and postsurveys were administered to the students using Qualtrics and took approximately five minutes to complete. The survey instrument consisted of 21 items measured on a five-point Likert response scale ranging from strongly disagree (1) to strongly agree (5). These items generally measured students’ understanding of the importance and benefits of IPE, perceptions toward dentists and pharmacists and openness to collaborate in the future. All students were assigned a unique code that they were instructed to enter on both surveys. This code was used solely for matching the pre- and postsurveys. The study was determined to be exempt from institutional review board (IRB) approval by the Loma Linda University Health IRB. All data were analyzed using SPSS version 25 (IBM Corp, 2017). Descriptive statistics (e.g., frequencies, means and standard deviations) were computed for all items. A repeated measures t-test as well as repeated measures generalized linear model were conducted to compare the mean differences in pharmacy and dental students’ attitudes toward IPC and IPE before and after the event and by gender and profession. A p-value of less than or equal to 0.05 was considered to be statistically significant. M AY 2 0 2 1

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TABLE 2

Pre and Post Mean Comparisons Item

Pre mean (SD)

Post mean (SD)

P–value

Learning with other students/professions will help me become a more effective member of a health care team.

4.32 (0.8)

4.34 (0.6)

–0.276

0.783

Patients would ultimately benefit if health care students/professionals worked together to solve patient problems.

4.50 (0.6)

4.41 (0.6)

1.549

0.124

Shared learning with other health care students will increase my ability to understand clinical problems.

4.30 (0.7)

4.34 (0.7)

–0.601

0.549

Learning with health care students from other disciplines before clinical practice would 4.27 (0.7) improve relationships during clinical practice.

4.34 (0.7)

–1.411

0.161

Communication skills should be learned with other health care students.

4.42 (0.6)

4.35 (0.7)

1.208

0.229

Shared learning will help me to think positively about other professionals.

4.20 (0.8)

4.29 (0.7)

–1.341

0.183

For small group learning to work, students/professionals need to trust and respect each other.

4.43 (0.7)

4.45 (0.5)

–0.323

0.747

Team-working skills are essential for all health care students to learn.

4.42 (0.7)

4.39 (0.6)

0.684

0.495

Shared learning with other health care students will help me to understand my own limitations.

4.25 (0.7)

4.29 (0.6)

–0.844

0.400

I do not want to waste my time learning with other health care students.

2.10 (1.0)

1.97 (1.1)

1.619

0.108

It is NOT necessary for health care students to learn together.

2.05 (1.0)

1.97 (1.0)

1.154

0.251

Clinical problem-solving skills should only be learned with students from my own discipline.

2.12 (1.1)

2.11 (1.0)

0.097

0.923

Shared learning with other health care students will help me to communicate better with patients and with other professionals.

4.24 (0.8)

4.23 (0.8)

0.108

0.914

I would welcome the opportunity to work on small group projects with other health care students.

4.01 (0.9)

4.18 (0.8)

–2.745

0.007

Shared learning with other health care students will help to clarify the nature of patient problems.

4.16 (0.8)

4.28 (0.7)

–2.142

0.034

Shared learning before clinical practice would help me become a better team worker.

4.20 (0.7)

4.24 (0.7)

–0.616

0.539

The function of pharmacists is mainly to dispense medication.

2.26 (1.1)

2.08 (1.1)

2.237

0.027

The function of dentists is mainly to restore teeth.

2.19 (1.2)

1.95 (1.1)

3.405

0.001

I am not sure how dentists and pharmacists can collaborate in patient care.

2.37 (1.0)

2.12 (0.9)

2.793

0.006

I have to acquire much more knowledge and skills than other health care students.

2.84 (1.0)

2.72 (1.0)

1.315

0.191

I am comfortable consulting with a dentist or pharmacist regarding patients’ oral, pharmaceutical and general health concerns.

3.72 (0.9)

4.07 (0.8)

–3.913

< 0.001

Strongly disagree = 1; strongly agree = 5 Degrees of freedom = 118

Results

A total of 163 students comprising 91 second-year dental students and 72 secondyear pharmacy students participated in the session (TA BLE 1). However, we were only able to match pre- and post-data for 119 students (73%) comprising 79 dental students (66.4%) and 60 pharmacy students (50.4%) (TA BLE 1). Both pharmacy and dental students had high mean attitude scores on all positively worded items and low means on 340 M AY

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all negatively worded attitude statements (TA BLE 2 ). The IPE event significantly improved dental and pharmacy students’ attitudes toward IPC on six of the 21 items assessed (p < 0.05). Following the event, students reported being more comfortable consulting with a dentist or pharmacist regarding a patient’s oral, pharmaceutical and general health outcomes (p < 0.001), realized the importance of interprofessional

collaboration between pharmacists and dentists (p < 0.001) and recognized the importance of shared learning for future clinical practice (p < 0.001, TA BLE 2 ) Verbal feedback from dental and pharmacy students indicated that they also appreciated the opportunity to build rapport and gain an understanding of each other’s profession. Many students showed interest in having more IPE sessions with other professions such as medicine and nursing.

C D A J O U R N A L , V O L 4 9 , Nº 5

TABLE 3

Mean Differences by Profession (Dental Students vs. Pharmacy Students) Item

Dentists means

Pharmacists means

P-value

Pre

Post

Pre

Post

Learning with other students/professions will help me become a more effective member of a health care team.

4.15

4.24

4.65

4.53

11.560

0.001

Patients would ultimately benefit if health care students/professionals worked together to solve patient problems.

4.37

4.30

4.78

4.63

13.645

< 0.001

Shared learning with other health care students will increase my ability to understand clinical problems.

4.19

4.18

4.53

4.65

11.385

0.001

Learning with health care students from other disciplines before clinical practice would improve relationships during clinical practice.

4.13

4.20

4.55

4.63

12.834

< 0.001

Communication skills should be learned with other health care students.

4.30

4.25

4.65

4,55

8.806

0.004

Shared learning will help me to think positively about other professionals.

4.04

4.19

4.53

4.48

9.085

0.003

For small group learning to work, students/professionals need to trust and respect each other.

4.32

4.33

4.65

4.68

11.674

0.001

Team-working skills are essential for all health care students to learn.

4.32

4.27

4.63

8.839

0.004

Shared learning with other health care students will help me to understand my own limitations.

4.11

4.18

4.53

10.390

0.002

I do not want to waste my time learning with other health care students.

2.27

2.13

1.78

1.68

6.851

0.010

It is NOT necessary for health care students to learn together.

2.27

2.19

1.63

1.55

13.947

< 0.001

Clinical problem-solving skills should only be learned with students from my own discipline.

2.32

2.29

1.73

1.75

10.250

0.002

Shared learning with other health care students will help me to communicate better with patients and with other professionals.

4.09

4.19

4.53

4.30

4.743

0.031

I would welcome the opportunity to work on small group projects with other health care students.

3.75

3.99

4.53

4.55

21.802

< 0.001

Shared learning with other health care students will help to clarify the nature of patient problems.

3.99

4.14

4.50

4.55

15.506

< 0.001

Shared learning before clinical practice would help me become a better team worker.

4.00

4.11

4.60

4.48

16.422

< 0.001

The function of pharmacists is mainly to dispense medication.

2.54

2.25

1.70

1.73

13.406

< 0.001

The function of dentists is mainly to restore teeth.

2.33

2.04

1.93

1.78

2.557

0.113

I am not sure how dentists and pharmacists can collaborate in patient care.

2.48

2.33

2.15

1.70

9.507

0.003

I have to acquire much more knowledge and skills than other health care students.

2.75

2.71

3.03

2.75

0.909

0.342

I am comfortable consulting with a dentist or pharmacist regarding patients’ oral, pharmaceutical and general health concerns.

3.57

4.06

4.03

4.08

2.734

0.101

Pharmacy students had significantly more positive opinions about IPE than dental students on 18 of the 21 items investigated (p < 0.05). For example, pharmacy students were more likely than dental students to agree with the following statements: ■ “Learning with other students/ professions will help me become a more effective member of a health care team.”

“Learning with health care students from other disciplines before clinical practice would improve relationships during clinical practice.” ■ “Shared learning with other health care students will help me to understand my own limitations.” Pharmacy students were also significantly more likely to disagree with the following statements than dental students: ■

“It is not necessary for health care students to learn together.” ■ “Clinical problem-solving skills should only be learned with students from my own discipline.” (TA BLE 3 ). There were statistically significant differences in the students’ attitudes toward IPE by gender on 17 of the 18 items investigated (p < 0.05). In general, female students were more likely to have more favorable opinions ■

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TABLE 4

Mean Differences in Attitude by Gender Item

Males means

P-value

Pre

Post

Pre

Post

Learning with other students/professions will help me become a more effective member of a health care team.

4.16

4.21

4.47

4.45

5.709

0.019

Patients would ultimately benefit if health care students/professionals worked together to solve patient problems.

4.48

4.27

4.53

4.55

2.842

0.095

Shared learning with other health care students will increase my ability to understand clinical problems.

4.05

4.11

4.53

4.55

16.717

0.001

Learning with health care students from other disciplines before clinical practice would improve relationships during clinical practice.

4.09

4.20

4.43

4.48

7.385

0.008

Communication skills should be learned with other health care students.

4.27

4.18

4.57

4.52

9.405

0.003

Shared learning will help me to think positively about other professionals.

3.96

4.09

4.42

4.47

11.539

0.001

For small group learning to work, students/professionals need to trust and respect each other.

4.29

4.34

4.57

4.55

6.370

0.013

Team-working skills are essential for all health care students to learn.

4.27

4.23

4.57

4.53

7.650

0.007

Shared learning with other health care students will help me to understand my own limitations.

4.14

4.16

4.35

4.43

4.222

0.042

I do not want to waste my time learning with other health care students.

2.27

2.23

1.97

1.73

5.198

0.024

It is NOT necessary for health care students to learn together.

2.34

2.32

1.80

1.67

12.881

< 0.001

Clinical problem-solving skills should only be learned with students from my own discipline.

2.36

2.43

1.87

1.80

11.153

0.002

Shared learning with other health care students will help me to communicate better with patients and with other professionals.

4.07

4.16

4.38

4.28

3.192

0.077

I would welcome the opportunity to work on small group projects with other health care students.

3.79

3.98

4.23

4.37

8.457

0.004

Shared learning with other health care students will help to clarify the nature of patient problems.

4.04

4.09

4.28

4.45

6.436

0.013

Shared learning before clinical practice would help me become a better team worker.

4.04

4.02

4.35

4.43

9.714

0.002

The function of pharmacists is mainly to dispense medication.

2.57

2.36

1.93

1.80

10.985

0.001

The function of dentists is mainly to restore teeth.

2.50

2.21

1.90

1.70

8.269

0.005

I am not sure how dentists and pharmacists can collaborate in patient care.

2.66

2.39

2.11

1.85

13.603

< 0.001

I have to acquire much more knowledge and skills than other health care students.

2.79

2.93

2.90

2.53

0.771

0.382

I am comfortable consulting with a dentist or pharmacist regarding patients’ oral, pharmaceutical and general health concerns.

3.75

4.07

3.68

4.07

0.069

0.794

about IPE than male students (p < 0.05, TA BLE 4 ).

Discussion

The mean pre- and postsurvey attitude scores for most of the 21 positively worded items were high indicating that students in general had favorable opinions about IPC, teamwork and learning. Similarly, previous studies also found that students viewed IPE and IPC positively.6,15 342 M AY

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These findings suggest that students appreciate the importance of effective collaboration between providers from different disciplines. Given the emphasis on IPE in health professions accreditation standards, more IPE opportunities and experiences will be offered to students in the future. The IPE experiences educate health professions students about their future scope of practice and roles of other health care professionals.

Females means

Despite the short duration of the IPE session, students’ attitudes toward IPE on six of the 21 items showed a statistically significant improvement between the preand postsurvey (p< 0.05). The IPE event improved dental and pharmacy students’ attitudes toward IPE, IPC and acceptance of other health care professions consistent with other studies on IPE.6,16,17 The IPE session gave dental and pharmacy students a rare but important opportunity to

C D A J O U R N A L , V O L 4 9 , Nº 5

interact with other health professions students. Exposing professional students to IPE cultivates IPC and teamwork through clarifying expectations for students who might otherwise adopt a traditional silo approach to working in health care and equipping students with requisite skills and knowledge for effective collaboration with other health care professionals.1,2 It is hoped that the opportunity to learn together given to those students will make it easier and more likely for them to work together when they graduate. Hosting this IPE was beset with several logistical challenges including lack of time, scheduling complications and lack of adequate venues and other resources. Similar and more challenges have been reported in the literature including faculty’s comfort level with IPE and crowded curriculum.18–20 Other studies have reported that lack of administrative and faculty support13,18,19 was an impediment, but this was not a major issue in our case. Overcoming these barriers is possible with committed faculty and support from administrators and the availability of adequate classroom space. It is unclear why pharmacy students had significantly more favorable opinions about IPE than dental students in general. However, oral health care professionals tend to care for their patients “with limited interaction with other health care professionals in a clinical setting”7,21 and as leaders of the oral health care team.22 Traditionally, dentists were trained in a “silo” approach and tended to work in isolation from other health care professionals.23 On the other hand, pharmacists by nature of their practice tended to work with many other health care professionals including physicians, nurses and social workers among others. Other studies

have found that pharmacy students had significantly more favorable attitudes toward IPC than dental students.13,16,17,22 More studies are needed to explore this association. This study found that female students had significantly more favorable attitudes than male students on most items. Previous studies found that having women in the group significantly improved collaboration.24–26 Women have been found to exhibit “higher levels of social sensibility” than men24 and to be better at reading nonverbal cues and interpreting what others are feeling.27 These factors may explain why female students had more favorable attitudes on IPE than males. More research needs to be conducted to further explore the relationship between gender and the students’ attitude toward IPE.

Limitations

This study has several limitations. First, there were more dental students than pharmacy students, and dental students tended to dominate during the discussion sessions and in responding to questions. Second, social desirability response bias may not be completely ruled out. However, there was no incentive for the students to be dishonest given that their responses were anonymous. Third, the one-time event was only two-hours long. More time is needed to expose students to IPE at different time periods throughout the curriculum. Such interventions are more likely to improve the students’ attitudes, skills and knowledge of IPE. Fourth, some students forgot to provide their unique codes on their survey making it difficult to match the pre- and postsurveys for these students. Fifth, this study did not assess the clinical critical-thinking

skills of pharmacy and dental students individually versus interprofessionally. Sixth, this study only included students from one university in California and the results may not be representative of all dental and pharmacy students in California or in the United States.

Conclusion

Pharmacy and dental students had favorable attitudes toward IPE before and after the IPE event. The IPE event was associated with a significant improvement in students’ attitudes toward interprofessional education and collaboration. Pharmacy and female students had more favorable attitudes toward IPE than dental and male students, respectively. n RE F E RE N C E S 1. Johnson KL, Fuji KT, Franco JV, et al. A pharmacist’s role in a dental clinic: Establishing a collaborative and interprofessional education site. Innov Pharm 2018;9(4):13–13. doi.org/10.24926/iip.v9i4.1382. 2. Buring SM, Bhushan A, Broeseker A, et al. Interprofessional education: Definitions, student competencies and guidelines for implementation. Am J Pharm Educ 2009 Jul 10;73(4):59. doi: 10.5688/ aj730459. 3. Gilbert JH, Yan J, Hoffman SJ. A WHO report: Framework for action on interprofessional education and collaborative practice. J Allied Health Fall 2010;39 Suppl 1:196–7. 4. Myers Virtue S, Rotz ME, Boyd M, et al. Impact of a novel interprofessional dental and pharmacy student tobacco cessation education programme on dental patient outcomes. J Interprof Care 2018 Jan;32(1):52–62. doi: 10.1080/13561820.2017.1378171. Epub 2017 Oct 23. 5. Rotz ME, von Vital R, Radovanovich A, et al. Impact of an interprofessional practice experience on medication histories within a dental admissions clinic. J Interprof Educ Pract 2018 Mar;10:15–23. doi.org/10.1016/j. xjep.2017.10.006. 6. Pogge EK, Hunt RJ, Patton LR, et al. A pilot study on an interprofessional course involving pharmacy and dental students in a dental clinic. Am J Pharm Educ 2018 Apr;82(3):6361. doi: 10.5688/ajpe6361. 7. Branch-Mays GL, Pittenger AL, Williamson K, et al. An interprofessional education and collaborative practice model for dentistry and pharmacy. J Dent Educ 2017 Dec;81(12):1413–1420. doi: 10.21815/JDE.017.101. 8. Theodorou J, Rotz M, Macphail L, et al. Designing and evaluating an interprofessional practice experience involving dental and pharmacy students. Am J Pharm Educ M AY 2 0 2 1

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2018 Aug;82(6):6298. doi: 10.5688/ajpe6298. 9. Conway SE, Smith WJ, Truong TH, Shadid J. Interprofessional pharmacy observation activity for thirdyear dental students. J Dent Educ 2014 Sep;78(9):1313– 8. 10. Commission on Dental Accreditation. Accreditation standards for dental education programs; 2010. 11. Accreditation Council for Pharmacy Education. Accreditation standards and key elements for the professional program in pharmacy leading to the Doctor of Pharmacy degree. Chicago; 2015. 12. Gupta B, Nanda A, Jain V, Verma M. Interprofessional education: A reform plan for collaborative. Contemp Clin Dent 2017 Jan–Mar;8(1):3–6. doi: 10.4103/0976237X.205035. 13. Davis J, Janczukowicz J, Stewart J, Quinn B, Feldman C. Interprofessional education in dental education: An international perspective. Eur J Dent Educ 2018 Mar;22 Suppl 1:10–16. doi: 10.1111/eje.12341. 14. Kim TE, Shankel T, Reibling ET, et al. Healthcare students interprofessional critical event/disaster response course. Am J Disaster Med Winter 2017;12(1):11–26. doi: 10.5055/ajdm.2017.0254.

15. Wilhelm M, Poirier T, Otsuka A, Wagner S. Interprofessional ethics learning between schools of pharmacy and dental medicine. J Interprof Care 2014 Sep;28(5):478–80. doi: 10.3109/13561820.2014.911722. Epub 2014 Apr 28. 16. Leong C, Louizos C, Currie C, et al. Student perspectives of an online module for teaching physical assessment skills for dentistry, dental hygiene and pharmacy students. J Interprof Care 2015;29(4):383–5. doi: 10.3109/13561820.2014.977380. Epub 2014 Nov 6. 17. Wamsley M, Staves J, Kroon L, et al. The impact of an interprofessional standardized patient exercise on attitudes toward working in interprofessional teams. J Interprof Care 2012 Jan;26(1):28–35. doi: 10.3109/13561820.2011.628425. 18. Rafter ME, Pesun IJ, Herren M, et al. A preliminary survey of interprofessional education. J Dent Educ 2006 Apr;70(4):417–27. 19. Newhouse RP, Spring B. Interdisciplinary evidencebased practice: Moving from silos to synergy. Nurs Outlook Nov–Dec 2010;58(6):309–17. doi: 10.1016/j. outlook.2010.09.001. 20. Smith EL, Cronenwett L, Sherwood G. Current

assessments of quality and safety education in nursing. Nurs Outlook May–Jun 2007;55(3):132–7. doi: 10.1016/j. outlook.2007.02.005. 21. Valle-Oseguera C, Boyce EG. Dentists and pharmacists: Paradigm shifts and interprofessional collaborative practice models. J Calif Dent Assoc 2015 Oct;43(10):591–5. 22. McGregor MR, Lanning SK, Lockeman KS. Dental and dental hygiene student perceptions of interprofessional education. J Dent Hyg 2018 Dec;92(6):6–15. 23. DePaola DP. The revitalization of U.S. dental education. J Dent Educ 2008 Feb;72(2):28–42. 24. Woolley AW, Chabris CF, Pentland A, Hashmi N, Malone TW. Evidence for a collective intelligence factor in the performance of human groups. Science 2010 Oct 29;330(6004):686–8. doi: 10.1126/science.1193147. Epub 2010 Sep 30. 25. Myaskovsky L, Unikel E, Dew MA. Effects of gender diversity on performance and interpersonal behavior in small work groups. Sex Roles 2005 May;52(9):645–57. doi.org/10.1007/s11199-005-3732-8. 26. Mannix E, Neale MA. What differences make a difference? The promise and reality of diverse teams in organizations. Psychol Sci Public Interest 2005 Oct;6(2):31–55. doi: 10.1111/j.15291006.2005.00022.x. Epub 2005 Oct 1. 27. Bear JB, Woolley AW. The role of gender in team collaboration and performance. Interdiscipl Sci Rev 2011;36(2):146–53. doi.org/10.1179/03080181 1X13013181961473. T HE CORRE S P ON DIN G AU T HOR , Alireza Hayatshahi, PharmD, BCPS, can be reached at ahayatshahi@llu.edu.

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Findings in Oral Health: Attitudes and Quality of Life Among Patients Experiencing Homelessness Hazem Seirawan, DDS, MPH, MS; Laura Elizondo, DDS; Niel Nathason, MPH, MS; and Roseann Mulligan, DDS, MS

abstract Background: The goal of this study was to evaluate access to dental care, oral health attitudes, oral health-related quality of life (OHRQoL) and satisfaction with received dental care among people experiencing homelessness (PEH) who are receiving dental services from a safety net program in downtown Los Angeles. Methods: The subjects were read the study questions in two separate interviews at baseline and follow-up assessing health attitudes and OHRQoL. Results: The study recruited 80 subjects. OHRQoL average scores improved from 35 to 26 points over the study period. The program resulted in a statistically significant reduction in the extent and prevalence of the OHRQoL scores with an improvement of 46.9% and 26.1% respectively. Subjective saliva indicators were statistically significantly associated with poorer total and partial scores of the Oral Health Impact Profile (OHIP-14). The subjects were satisfied with the providers and the services they received. Conclusions: The study found that providing adequate access to oral health care for PEH should reduce the severity of their oral health diseases and thus reduce the associated negative impacts on their OHRQoL. Practical implications: Community and private clinics should be supported in providing better access to oral health care for PEH and educated about the role of this access on employability, acceptability, rehabilitation and reintegration of PEH in our society. Key words: Oral health, quality of life, homelessness

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AUTHORS Hazem Seirawan, DDS, MPH, MS, is a clinical associate professor and the section chair of the CHAMP project in the division of dental public health and pediatric dentistry at the Herman Ostrow School of Dentistry of USC. He is a practicing pediatric dentist and a diplomate of the American Academy of Pediatric Dentistry. Conflict of Interest Disclosure: None reported. Laura Elizondo, DDS, is an associate professor of clinical dentistry at the Herman Ostrow School of Dentistry of USC and the director of the USC Dental Clinic at the Union Rescue Mission. Conflict of Interest Disclosure: None reported.

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Niel Nathason, MPH, MA, is an associate professor emeritus of clinical dentistry at the Herman Ostrow School of Dentistry of USC. Conflict of Interest Disclosure: None reported. Roseann Mulligan DDS, MS, is the Charles M. Goldstein professor of community oral health and an associate dean of community health programs and hospital affairs at the Herman Ostrow School of Dentistry of USC. Conflict of Interest Disclosure: None reported.

he highly diverse U.S. population experiencing homelessness continues to increase in number.1 It is estimated that while there are over 57,000 individuals without housing in Los Angeles County at any one time, there are over 190,000 people experiencing homelessness (PEH) per year.2 Access to health care is vital to an individual’s well-being. While many Los Angeles County residents struggle with the high costs of health care, those without housing are particularly vulnerable to multiple unique challenges regarding their health. About a quarter (24%) are unable to receive needed medical care with nearly half (48%) visiting hospital emergency rooms and 52% suffering from depression.3 Clearly, the accessibility of safety net programs is suboptimum.4 Good general and oral health is considered an essential factor in helping PEH return to the workforce and resume productive roles in society.1 Yet published studies describing their poor oral health conditions, lack of access to dental care and the associated burden on the quality of life are scarce.1,5–10 To help PEH in their rehabilitation and to reduce the impact of poor oral health conditions on their quality of life, the Herman Ostrow School of Dentistry of USC and the Union Rescue Mission (URM) established a community dental clinic in 1999 to provide comprehensive oral health care and thereby improve and maintain the oral health of PEH in downtown Los Angeles. The authors previously described the development of the USC+URM Dental Clinic in downtown Los Angeles, illustrating its success as a model of a community-campus partnership developed to improve the access of dental care among those without housing, and reported on the high prevalence of oral

health disease among PEH including untreated caries (58%) with a mean of 6.3 decayed teeth at baseline.11 In this study, we evaluated access to dental care, attitudes toward oral health and dental care, oral health-related quality of life (OHRQoL) status and satisfaction with received dental care among PEH treated at this dental clinic.

Methods

PEH who were first-time visitors to the USC+URM Dental Clinic and who were enrolled in a rehabilitation program were eligible for the study and were invited to participate by bilingual staff (English/Spanish). This group represents a convenience sample recruited over a three-month period. During the first interview (baseline), participants were asked questions about their access to dental care, OHRQoL, attitudes toward oral health and dental care. The second interview (followup) occurred about six months after the first dental appointment and again asked questions about their OHRQoL, attitudes toward oral health and dental care and satisfaction with the dental care they received. The study obtained approval and satisfied the University of Southern California Institutional Review Board (UP-06-00279). The questions asked during the interviews were adapted from previously published questionnaires. For example, access to dental care was evaluated using the Association of State and Territorial Dental Directors questionnaire instrument.12 The short version of the Oral Health Impact Profile instrument (OHIP-14) was used for the OHRQoL.13 This instrument is composed of 14 questions with a five-point Likert scale response system. Attitudes toward oral health and dental care were also evaluated using a structured questionnaire designed

C D A J O U R N A L , V O L 4 9 , Nº 5

TABLE 1

Sociodemographic Data at Baseline and Follow-Up ± Characteristics

Baseline interview

Follow-up interview

18–39

23.8

17.2

40–49

45.0

44.8

50+

31.3

37.9

Male

78.8

86.2

Female

21.3

13.8

Caucasian

26.9

35.7

African American

48.7

57.1

Hispanic

24.4

7.1

< 6 months

52.1

6 months — 1 year

26.8

> 1 year

21.1

Mouth feels dry when eating a meal? **

32.1

Needs to sip liquids when swallowing dry foods? **

33.8

too little

10.1

too much

10.1

did not notice

79.8

Yes

63.3

Total

100.0

Age (mean 45 years, range 21–62 years)

by the World Health Organization Collaborating Centre (WHO CC) for Community Oral Health Programs and Research14 where a five-point Likert scale ranging from “strongly agree” to “strongly disagree” was used. Other questions were added about the subjective feeling of the amount of saliva in the mouth (based on the subjective parameters develop by Fox et al.15), smoking habits, consumption of alcohol and satisfaction with received dental services. Responses to the satisfaction questions were also recorded on a five-point Likert scale ranging from “very satisfied” to “very dissatisfied.”

Statistical Analysis

Descriptive statistics from the questionnaire were generated for all study variables. OHRQoL questions were coded from 0 to 4 where 0 indicated never and 4 indicated very often. The overall weighted sum of scores of OHRQoL questions and the partial scores by domains were calculated to measure OHRQoL severity. OHRQoL prevalence was calculated as the proportion of people reporting at least one answer as fairly often or very often. The number of questions answered by a subject as fairly often or very often is the subject’s OHRQoL extent.16 The attitude variables from the WHO CC instrument were dichotomized as strongly agree versus all other categories. The satisfaction variables were dichotomized as very satisfied versus all other categories. The independent variables were age, gender, race/ethnicity, length of homelessness, saliva indicators and currently smoking. General linear models were used to quantify the association between OHRQoL and the independent variables.

Results

The study recruited 80 consecutive subjects for the baseline interview. All subjects invited to join the study agreed

Gender ***

Race/ethnicity *

Time experiencing homelessness **

Saliva indicator

Amount of saliva seems to be: ***

Currently smoking *

± Statistical tests are based on chi square * p < .05 level, ** p < .01 level, *** p < .001 level

to participate. The majority were males (78.8.%), with 45.0% being 40–49 years of age and most commonly African American (48.7%). Twenty-nine subjects (36.3%) were available for the follow-up interview. The follow-up sample was not significantly different in terms of age, gender or race/ ethnicity compared to the baseline sample. More than half of the baseline sample of subjects (52.1%) were newly lacking a home (less than six months). About onethird of them reported the sensation of a dry mouth when eating (32.1%) or needed to sip water to aid in swallowing dry food (33.8%) with greater than half of them

being current smokers (63.3%) (TA BLE 1 ). Just over half (52.6%) recalled a toothache during the last six months and 53.3% had unmet dental needs in the last year. Only two African American women were enrolled in the state Medicaid program (Denti-Cal) (TA BLE 2 ). The reader is advised to review the authors’ earlier publication about the USC+URM Dental Clinic for more in-depth analyses of the oral health conditions of the clinic’s target population.11 TA BLE 3 describes the attitudes of the study subjects toward oral health (measured by the WHO CC M AY 2 0 2 1

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TABLE 2

Access to Dental Care at Baseline α Characteristics

Toothache (last 6 months)

Unmet dental needs (past 1 year )

Denti-Cal

18–39

44.4

72.2

5.3

40–49

55.6

52.9

2.9

50+

54.2

39.1

0.0

Male

53.2

50.9

0.0

Female

50.0

62.5

11.8 β

Age

Gender

Race/ethnicity Caucasian

42.9

57.1

0.0

African American

60.5

54.1

5.3

Hispanic

41.2

40.0

0.0

Total

52.6

53.3

2.5

α Statistical tests are based on chi square β Gender and Denti-Cal status are not independent variables * p < .05 level, ** p < .01 level, *** p < .001 level

instrument14). With the exception of the attitude statement about the focus of dentists being on treatment more than prevention, at the baseline interview more than half of the subjects strongly agreed with all the different attitude statements. Over half of the subjects at the baseline strongly agreed about the importance of the appearance of teeth (77.5%) and that going to the dentist solves oral health problems (66.3%). At the follow-up interview, subjects had even more favorable attitudes toward dentists than during the baseline interview, with a statistically significant improvement being seen for the two attitudes: dentists explaining problems (an improvement of 63.6% (p < .01) and dentists devoting attention to patients (an improvement of 61.5% (p < .05). An interesting attitude statement that received a lower score than expected was related to sugar consumption with only 61.3% (baseline) and 79.3% (follow-up) of the subjects strongly agreeing that sweet products were bad for teeth. The strongest favorable changes in attitudes between the two interviews were in the effect of brushing on periodontal health and the role of 348 M AY

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dentists in solving problems with all subjects who did not strongly agree with these statements during the baseline interview strongly agreeing with them at the follow-up interview. TA BLE 4 describes the OHRQoL of the study subjects with lower scores being better. At baseline, the subjects scored 34.9 points or 63% of the maximum score possible, which would equal the worst OHRQoL. The worst partial scores were in psychological discomfort (8.0) followed by the psychological disability (6.4) dimensions of the instrument. The best partial scores were in the functional limitation (2.2) and physical disability (3.8) dimensions of the instrument. OHRQoL scores were improved when measured at the second interview with an average total score of 26.1 points or 46% of the maximum score possible. Follow-up partial scores had the same patterns of the baseline partial scores with subjects scoring the highest in the psychological discomfort (6.7) and psychological disability (4.2) dimensions and the lowest in the functional limitation (2.3) and physical disability (2.1) dimensions. Changes in total OHRQoL scores and

in the partial scores of the physical pain, physical disability, psychological disability and handicap dimensions were statistically significant and in the desirable direction. The strongest improvement was in the scores of the physical disability and handicap dimensions, which both increased by 44.5% and 38.0% respectively at the follow-up interview. The weakest improvement was 19.3% in the psychological discomfort dimension (TA BLE 4 ). Total OHRQoL scores at baseline were not explained by age, gender or race/ethnicity except that participants in the age group 40–49 had the highest mean total score of 42.9 compared to 18.7 and 35.4 in the age groups 18–39 and 50-plus respectively (p = 0.004) (data not shown). Nor were changes in OHRQoL scores explained by age, gender and ethnicity except that psychological discomfort was found to be statistically significantly different by the age groups after adjusting for baseline scores (p = 0.028); participants in the age group 40–49 had an increased score of 0.15 of a point in psychological discomfort between the two interviews compared to decreases of 3.52 and 2.67 points in the age groups 18–39 and 50-plus respectively (data not shown). The USC+URM program resulted in a statistically significant reduction in the extent and prevalence of the poor OHRQoL scores with an improvement of 46.9% (in 69% of the subjects) and 26.1% respectively. TA BLE 5 further describes the OHRQoL of the study subjects by their subjective saliva indicators. Both measures of “dry mouth when eating a meal” and “needs to sip liquids when swallowing dry foods” were statistically significantly associated with poorer total and partial scores of OHRQoL. Participants whose mouths felt dry when eating had more than double the OHIP-14 scores of those who did not (54.1 versus 25.9, p < 0.001);

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TABLE 3

Percentage of Subjects Who Strongly Agreed With These Attitude Statements Toward Oral Health and Dental Care (measured by the WHO CC instrument) α Attitude statements

Baseline interview

Follow-up interview

Change β

N = 80

N = 29

Appearance of teeth is important

77.5

93.1

85.7

Sweets are bad for teeth

61.3

79.3

71.4

Tobacco is bad for oral health

70.0

93.1

90.9

Brushing is good for teeth

70.0

89.7

90.9

Brushing is good for gum

67.5

96.6

100.0

Going to dentists solves oral health problems

66.3

93.1

100.0

Dentists explain problems to patients

61.3

86.2

63.6 **

Dentists devote attention to patients

56.3

79.3

61.5 *

Dentists examine patients carefully

55.0

89.7

93.3

Dentists prefer treatment over prevention

15.0

34.5

37.5

α Statistical tests are based on Kendall’s tau-b β % calculated as number of subjects who scored less than strongly agreed in the pretest and strongly agreed in the post-test divided by the number of subjects who scored less than strongly agreed in the pretest * p < .05 level, ** p < .01 level, *** p < .001 level

and participants who needed liquids when swallowing had almost double the scores of those who did not (50.1 versus 27.1, p < 0.001). The pattern was similar for all partial OHRQoL scores. Participants who did not notice that their saliva was “too much” or “too little” also had significantly better total and partial scores except in the area of social disability, where the trend did not reach significance. When the extent and prevalence measures of OHRQoL were calculated by saliva indicators, statistically significant higher OHRQoL scores were found for those with dry mouth or needing to sip liquids when eating (TA BLE 5 ). Length of homelessness did not seem to have an effect on OHRQoL scores, but smokers seem to have poorer total scores by 13.4 points with a p = 0.025 (data not shown). Overall, the subjects were very satisfied with the providers and services they received at the follow-up interview. Over 93% were very satisfied with the staff services (front desk and chairside) and over 86% were very satisfied with the dentist. About two-thirds of the subjects (69%) were very satisfied with their smiles and 62% were very satisfied with their quality of life subsequent to treatment. The majority of the subjects believed that their new smiles helped them become

more employable (86%) and socially acceptable (93%) (data not shown).

Discussion

Homelessness is more than just a lack of safe and secure housing. It results in social isolation and vulnerability to risky health behaviors and chronic health problems.17 Our study is the first U.S. study to use the OHIP-14 — a validated and known instrument — to better understand the OHRQol of PEH in the U.S. Our study is also the first to study their OHRQoL at two points of time over a timespan of six months. The response rate to our follow-up study was 36%, which is a reasonable outcome given the transient nature of our subjects and their complex social and psychosocial challenges. PEH experience a burden of medical conditions and poorer oral health than the general public.16 The authors have reported in a previous publication about the community health project USC+URM Dental Clinic and concluded that PEH visiting the clinic are in great need of restorative, surgical and periodontal procedures. The findings were consistent with other U.S. and international studies describing the high rates of dental diseases among PEH.11 For

example, 41% of PEH in the U.S. were found to have unmet dental needs.18 The number of decayed teeth among PEH was estimated to be seven teeth in Stockholm, Sweden,8 four in Belfast, Ireland,19 three in Hong Kong9 and 5.8 in Boston,6 which was similar to our study of 6.3. The results are consistent with the World Health Organization Report and the U.S. surgeon general report that the burden of oral diseases is the greatest among disadvantaged groups such as PEH.20,21 The USC+URM Dental Clinic continues to be a successful oral health care delivery model for PEH. It is deeply incorporated in the rehabilitation programs of the URM main facility programs and other local rehabilitating agencies that refer PEH for comprehensive care.11 Previous oral health research on PEH in the U.S. has tended to focus on their clinical oral conditions. However, the psychosocial and social impacts of diseases are as important as the classic epidemiological measures.22 One study in the U.S. by Conte et al. found in a sample of 46 PEH subjects participating in a homeless service day in New Jersey that the majority reported one or more negative oral health impacts. Eating difficulty was reported by 42% of the M AY 2 0 2 1

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TABLE 4

Oral Health-Related Quality of Life Among PEH α OHRQOL measures

Baseline interview

Follow-up interview

n = 78

n = 29

Mean score improvement

Percentage improvement

Severity (mean/std)

Mean

Std

Mean

Std

Mean

Std

Total

34.9

25.5

26.1

24.2

10.1

13.8

29.1

***

OHRQOL dimensions Functional limitation

2.2

2.8

2.3

2.5

0.5

2.4

24.9

Physical pain

4.8

3.3

3.7

2.6

1.0

1.8

21.8

Psychological discomfort

8.0

6.2

6.7

6.1

1.6

5.3

19.3

Physical disability

3.8

3.4

2.1

2.5

1.7

2.1

44.5

***

Psychological disability

6.4

5.0

4.2

4.3

2.4

4.1

37.2

Social disability

5.7

6.2

4.1

5.7

1.4

4.4

25.0

Handicap

4.0

4.1

2.9

3.9

1.5

3.2

38.0

Extent (mean/std)

5.2

4.5

3.1

4.1

2.4

2.8

46.9

75.6

58.6

26.1 **

Prevalence n (%)

α Lower values indicate better OHRQOL β Statistical tests are based on signed rank test for the difference † In 20 subjects (69% of the sample) * p < .05 level, ** p < .01 level, *** p < .001 level

subjects followed by unease or difficulty in smiling (33%), concentration (18%) and talking (16%). The study concluded that the negative impact of oral health on daily activities was higher than expected and typically unreported.10 In this study, we focus on the impact of oral health on the quality of life in our target population. There are several studies about the OHRQoL of PEH in the U.K. and Australia. Daly et al. studied a convenience sample of 93 PEH subjects drawn from eight facilities in South East London who were invited to participate in an oral health assessment in an outreach dental clinic. The study used the OHIP-14 instrument and found poor OHRQoL with an overall mean impact (severity) score of 32 compared to our study of 34.9 at baseline and 26.1 at follow-up.23 Another study in the U.K. by Richard et al. studied 100 vulnerable PEH subjects who were using the services of a community center in Swansea, South Wales. The subjects were invited to complete the OHIP-14 instrument. The study found an overall mean impact score 350 M AY

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of 21.8 with the most common impacts being related to toothache, discomfort (physical pain), ability to relax and feeling ashamed regarding the appearance of teeth (psychological disability).22 In our study, psychological disability and psychological discomfort were the strongest adverse impacts at both baseline and follow-up, rather than physical pain. While Ford et al. theorized that PEH might be more accepting of greater levels of oral pain because of the small difference (1.0 point) in OHRQoL found between the general population and PEH in the psychological domain (smaller than any other domains),16 we propose that our subjects’ recent access to dental care that may have alleviated any possible pain complaints might explain the moderate impact of physical pain seen in our study (1.0 point or 21.8%). The South Wales study also found that homeless status and tooth loss were the strongest predicting factors of poorer OHIP-14 scores with rough sleeping (sleeping outside because the individual has no home) and those with less than 19 teeth being more likely to be in this category.22 It should be mentioned that the OHIP-14 was administered in the Adult Dental Health Survey of the

* †

***

U.K. in 1998 with a resulting overall mean impact score of 5.1 for the general population.24 Another study in Brisbane, Australia, examined the adverse impact of oral health problems and quality of life of a convenience sample of urban adult PEH subjects using the OHIP-14 instrument. In this study, the oral health impact on quality of life was significantly greater across all measures when compared with the general Australian population by a magnitude of three times greater than the general population with the overall mean impact score at 28.6 compared to 7.5 in the Australian population. In this Australian study, the authors chose to combine the domains of physical pain and physical disability in one domain and did the same for the domains of psychological discomfort and physiological disability,16 thus we could not compare our partial scores. In the U.S., there is no national survey that employs OHIP-14 among adult Americans. The 2003–2004 NHANES employed a shorter version, comprised of only seven questions from the OHIP14 instrument. In the NHANES study, the prevalence of OHRQoL was 15.3% with a mean impact score of 2.81,25 compared to our study with a prevalence

C D A J O U R N A L , V O L 4 9 , Nº 5

TABLE 5

Oral Health-Related Quality of Life Among PEH by Saliva Indicator at Baseline α OHRQoL measures

Mouth feels dry when eating a meal?

Need to sip liquids when swallowing dry foods?

Amount of saliva seems to be:

Severity (mean/std)

Yes

Too little

Too much

Did not notice

Mean

StD

Mean

StD

Mean

StD

Mean

StD

Mean

StD

Mean

StD

Mean

StD

54.1 ***

18.8

25.9

23.3

50.1 ***

22.4

27.1

23.9

49.1

19.4

54.0

24.7

30.6 **

24.8

Functional limitation

3.9 ***

2.9

1.4

2.4

3.3 *

2.9

1.6

2.6

2.9

2.2

5.3

3.5

1.7 **

2.5

Physical pain

7.1 ***

2.3

3.6

3.0

6.4 ***

2.8

3.9

3.2

6.1

2.8

7.0

2.8

4.3 *

3.2

Psychological discomfort

11.7 ***

5.1

6.3

5.9

10.9 **

5.9

6.6

5.8

11.8

4.3

11.0

7.1

7.2 *

6.0

Physical disability

6.5 ***

2.5

2.6

3.0

6.1 ***

2.8

2.6

3.1

4.2

3.0

6.8

1.8

3.4 *

3.4

Psychological disability

10.0 ***

3.5

4.6

9.0 ***

4.5

5.1

4.7

9.5

2.9

8.8

4.1

5.6 *

5.0

Social disability

8.8 **

5.4

4.3

6.1

8.5 **

5.5

4.3

6.1

9.5

5.3

7.8

6.6

5.0

6.1

Handicap

6.2 **

4.4

3.0

3.6

6.0 **

3.8

3.0

4.0

5.1

4.4

7.2

3.9

3.5 *

3.9

Extent (mean/std)

8.8 ***

3.4

3.5

4.0

7.8 ***

4.3

3.9

4.1

7.4

3.8

8.9

4.5

4.4 **

4.3

25 ***

100

64.1

88.5

68.6

100.00

43 *

69.4

Total OHRQoL dimensions

Prevalence (%)

α Lower values indicate better OHRQoL * p < .05 level, ** p < .01 level, *** p < .001 level

of 75.6 and a mean of 5.2 at baseline. The large difference in the mean scores is due to the NHANES being based on the sum of seven items and the OHIP14 having 14 items.25 Our finding is still alarming given that the prevalence in our sample at follow-up is almost four times (58.6%) what is reported in the U.S. population (15.3%) and the services provided at the USC+URM Dental Clinic resulted in significant reduction in the severity, extent and prevalence of OHRQoL measures. Our study also sheds light on the high prevalence of subjectively assessed salivary gland dysfunction among PEH. In our relatively young sample (age range 18–62), about one-third of the subjects were affected by a subjective feeling of xerostomia, and these results correlated with a significant impact in

all dimensions of their OHRQoL. Other authors have published about the effect of xerostomia on OHRQoL among general adult populations in the U.S. and found that a feeling of mouth dryness while eating was a strong risk factor associated with poor OHRQoL. It was the third most important risk factor for poor OHRQoL in a multivariate analysis after perceived needs to relieve pain and to have a denture respectively (OR of 2.2).26 This effect seems to be as significant among our PEH sample with a feeling of dry mouth resulting in about double the OHRQoL scores compared to those without this feeling at baseline. The effects of xerostomia on OHRQoL have been documented among people with burning mouth syndrome,27 Sjogren’s syndrome,28 oral cancer29 and Type 1 diabetes.30 It is likely that our sample subjects may also be

suffering from other medical conditions with oral symptoms. Further investigation of the systemic and oral health of PHE and their OHRQoL is recommended. Oral health care provided by the USC+URM Dental Clinic resulted in the majority of PEH subjects in the sample perceiving themselves as more employable and socially acceptable at the end of the study. This is in spite of the fact that only 62% of them were satisfied with their quality of life in general. It is important to remind the reader that the participants in our study were part of a rehabilitation program that helped them tackle their intertwined and complex social and health problems at the same time they were receiving dental care. We recognize that there are some limitations to our study. Although our sample does not represent all PEH in M AY 2 0 2 1

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Los Angeles, it represents those who were enrolled in local rehabilitation programs and thus had access to oral health care through the USC+URM Dental Clinic. Our sample is not a probability-based sample, but it represents a diverse group of individuals in terms of age, gender and race/ethnicity. In conclusion, the oral health of PEH is quite poor and has negative impacts on their quality of life. Providing adequate access to oral health care for PEH should reduce the severity of their oral health diseases and thus reduce the associated negative effects on their OHRQoL. Furthermore, better access to oral health care should contribute to improving their employability, acceptability and satisfaction of PEH, with the goal being to contribute to their rehabilitation and reintegration as productive members of society.

Compliance With Ethical Standards

This study was funded by the Herman Ostrow School of Dentistry of USC and received approval from the USC’s Institutional Review Board (USC IRB UP-09-00020). All procedures performed in this study were in accordance with the ethical standards of the USC IRB. Informed consent was obtained from all individual participants included in the study. This article does not contain any studies with animals performed by any of the authors. n RE FEREN CE S 1. King TB, Gibson G. Oral health needs and access to dental care of homeless adults in the United States: A review. Spec Care Dentist Jul–Aug 2003;23(4):143–7. doi: 10.1111/j.1754-4505.2003.tb00301.x. 2. The Los Angeles Homeless Services Authority. 2013 Greater Los Angeles Homeless Count. Los Angeles: The Los Angeles Homeless Services Authority; 2014. 3. The Los Angeles Homeless Services Authority. 2007 Greater Los Angeles Homeless Count. Los Angeles: The Los Angeles Homeless Services Authority; 2007. 4. Kertesz SG, McNeil W, Cash JJ, et al. Unmet need for medical care and safety net accessibility

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among Birmingham’s homeless. J Urban Health 2014 Feb;91(1):33–45. doi: 10.1007/s11524-013-9801-3. 5. Gelberg L, Linn LS, Rosenberg DJ. Dental health of homeless adults. Spec Care Dentist Jul–Aug 1988;8(4):167–72. doi: 10.1111/j.1754-4505.1988. tb00725.x. 6. Kaste LM, Bolden AJ. Dental caries in homeless adults in Boston. J Public Health Dent Winter 1995;55(1):34–6. doi: 10.1111/j.1752-7325.1995.tb02328.x. 7. Gibson G, Rosenheck R, Tullner JB, et al. A national survey of the oral health status of homeless veterans. J Public Health Dent Winter 2003;63(1):30–7. doi: 10.1111/j.1752-7325.2003.tb03471.x. 8. De Palma P, Frithiof L, Persson L, et al. Oral health of homeless adults in Stockholm, Sweden. Acta Odontol Scand 2005 Feb;63(1):50–5. doi: 10.1080/00016350510019658. 9. Luo Y, McGrath C. Oral health status of homeless people in Hong Kong. Spec Care Dentist Jul–Aug 2006;26(4):150–4. doi: 10.1111/j.1754-4505.2006. tb01716.x. 10. Conte M, Broder HL, Jenkins G, et al. Oral health, related behaviors and oral health impacts among homeless adults. J Public Health Dent Fall 2006;66(4):276–8. doi: 10.1111/j.1752-7325.2006.tb04082.x. 11. Seirawan H, Elizondo LK, Nathason N, et al. The oral health conditions of the homeless in downtown Los Angeles. J Calif Dent Assoc 2010 Sep;38(9):681–8. 12. Association of State and Territorial Dental Directors. Basic screening surveys: An approach to monitoring community oral health. 2003. 13.Slade GD, Strauss RP, Atchison KA, et al. Conference summary: Assessing oral health outcomes — measuring health status and quality of life. Community Dent Health 1998 Mar;15(1):3–7. 14. Petersen PE, Aleksejuniene J, Christensen LB, et al. Oral health behavior and attitudes of adults in Lithuania. Acta Odontol Scand 2000 Dec;58(6):243–8. doi: 10.1080/00016350050217073. 15. Fox PC, Busch KA, Baum BJ. Subjective reports of xerostomia and objective measures of salivary gland performance. J Am Dent Assoc 1987 Oct;115(4):581–4. doi: 10.1016/s0002-8177(87)54012-0. 16. Ford PJ, Cramb S, Farah CS. Oral health impacts and quality of life in an urban homeless population. Aust Dent J 2014 Jun;59(2):234–9. doi: 10.1111/adj.12167. 17. Kermode M, Crofts N, Miller P, et al. Health indicators and risks among people experiencing homelessness in Melbourne, 1995–1996. Aust N Z J Public Health 1998 Jun;22(4):464–70. doi: 10.1111/j.1467-842x.1998. tb01415.x. 18. Baggett TP, O’Connell JJ, Singer DE, et al. The unmet health care needs of homeless adults: A national study. Am J Public Health 2010 Jul;100(7):1326–33. doi: 10.2105/ AJPH.2009.180109. Epub 2010 May 13. 19. Collins J, Freeman R. Homeless in North and West Belfast: An oral health needs assessment. Br Dent J 2007 May;202(12):E31. doi: 10.1038/bdj.2007.473. 20. Department of Health and Human Services. Oral Health in America: A Report of the Surgeon General. 2000. 21. Petersen PE. World Health Organization global policy for improvement of oral health — World Health

Assembly 2007. Int Dent J 2008 Jun;58(3):115–21. doi: 10.1111/j.1875-595x.2008.tb00185.x. 22. Richards W, Keauffling J. Homeless who accessed a healthy living centre in Swansea, South Wales: An assessment of the impact of oral illhealth. Prim Dent Care 2009 Jul;16(3):94–8. doi: 10.1308/135576109788634287. 23. Daly B, Newton T, Batchelor P, et al. Oral health care needs and oral health-related quality of life (OHIP-14) in homeless people. Community Dent Oral Epidemiol 2010 Apr;38(2):136–44. doi: 10.1111/j.16000528.2009.00516.x. Epub 2010 Jan 14. 24. Steele JG, Sanders AE, Slade GD, et al. How do age and tooth loss affect oral health impacts and quality of life? A study comparing two national samples. Community Dent Oral Epidemiol 2004 Apr;32(2):107–14. doi: 10.1111/j.0301-5661.2004.00131.x. 25. Sanders AE, Slade GD, Lim S, et al. Impact of oral disease on quality of life in the U.S. and Australian populations. Community Dent Oral Epidemiol 2009 Apr;37(2):171–81. doi: 10.1111/j.16000528.2008.00457.x. Epub 2009 Jan 17. 26. Seirawan H, Sundaresan S, Mulligan R. Oral health-related quality of life and perceived dental needs in the United States. J Public Health Dent Summer 2011;71(3):194–201. 27. Lopez-Jornet P, Juan H, Alvaro PF. Mineral and trace element analysis of saliva from patients with BMS: A crosssectional prospective controlled clinical study. J Oral Pathol Med 2014 Feb;43(2):111–6. doi: 10.1111/jop.12105. Epub 2013 Jul 19. 28. Mumcu G, Bicakcigil M, Yilmaz N et al. Salivary and serum B-cell activating factor (BAFF) levels after hydroxychloroquine treatment in primary Sjögren’s syndrome. Oral Health Prev Dent 2013;11(3):229–34. doi: 10.3290/j.ohpd.a30172. 29. Li W, Yang Y, Xu Z, et al. Assessment of quality of life of patients with oral cavity cancer who have had defects reconstructed with free anterolateral thigh perforator flaps. Br J Oral Maxillofac Surg 2013 Sep;51(6):497–501. doi: 10.1016/j.bjoms.2012.09.005. Epub 2012 Oct 26. 30. Busato IM, Ignacio SA, Brancher JA, et al. Impact of xerostomia on the quality of life of adolescents with Type 1 diabetes mellitus. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2009 Sep;108(3):376–82. doi: 10.1016/j. tripleo.2009.05.005. T HE CORRE S P ON DIN G AU T HOR , Hazem Seirawan, DDS, MPH, MS, can be reached at mhseirawan@gmail.com.

RM Matters

C D A J O U R N A L , V O L 4 9 , Nº 5

Treating Elderly Patients: Minimize Risk With Informed Consent and Updated Health History TDIC Risk Management Staff

ental professionals face a number of challenges in securing consent for oral care, but there are specific consent and documentation considerations when caring for older adults. When guiding patients through appropriate treatment options, dentists typically consider the patient’s medical status and financial resources; however, it is important to also be mindful of chronic illnesses or cognitive impairments that could affect their ability to consent to dental treatment or even accurately answer a health questionnaire. Many older adults may find it difficult to comprehend diagnostic information or treatment options and tend to rely on their health care provider, a trusted family member or caregiver to make critical treatment decisions on their behalf. The Dentists Insurance Company’s Risk Management Advice Line often receives calls from dentists who need guidance navigating complex patient care situations. In one case recently reported to the Advice Line, a 90-year-old patient, who had not been seen for a year, presented on an emergency basis with a broken tooth. Upon conducting a limited exam, the dentist noticed that a significant portion of the lingual cusp was missing and recommended a crown to restore the tooth. The patient was presented with a treatment estimate and consented to initiate treatment the same day. Prior to leaving the office, the patient provided a credit card for payment of the entire treatment cost. The office received a phone call the following day from the patient’s son inquiring about his father’s treatment. The son disputed that his father agreed to the charges and stated that his father was “forced” to go through with the treatment.

The son informed the office that his father recently suffered a stroke and was unable to make treatment or financial decisions. Therefore, he had power of attorney for his father’s financial and health care decisions. The son demanded that the office credit back the charge on the credit card and requested a copy of his father’s chart. As illustrated in this case, dentists should be mindful of several considerations when treating elderly patients, such as determining whether the patient is able to consent to treatment and ensuring their medical history is up to date.

Assessing a patient’s ability to consent to treatment

Although the dentist took the time to explain the risks, benefits and alternatives (RBA) of treatment, there was no documentation of this discussion in the patient’s chart. To prove the discussion occurred and help mitigate any potential liability risks, dentists must make a practice of documenting the informed consent discussion in the patient’s chart as “RBAs discussed and questions answered.” A key factor in obtaining informed consent is determining who is responsible for the patient’s treatment

answers

From one-on-one risk management advice by phone to informed consent forms to expert-led seminars, we’re here to help you practice with confidence. We are The Dentists Insurance Company. Learn more at tdicinsurance.com/rm

Protecting dentists. It’s all we do.

800.733.0633 | tdicinsurance.com | Insurance Lic. #0652783

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RM MAT TERS C D A J O U R N A L , V O L 4 9 , Nº 5

and financial decisions. The dentist is responsible for assessing whether the patient is capable of providing their consent prior to discussing RBAs. Treatment decision-making capacity has four key elements. There is a general agreement that a patient is considered capable of making a treatment decision if they can: ■ Demonstrate understanding of the benefits and risks of, and the alternatives to, a proposed treatment or intervention, including no treatment. ■ Demonstrate appreciation of those benefits, risks and alternatives. ■ Show reasoning in making a decision. ■ Communicate their choice. If the dentist is concerned about the patient’s ability to make their own treatment decisions, they should ask the patient if there is a trusted family member or caregiver who can consent to appropriate care on their behalf. For independent elderly patients, dentists should always obtain consent from the patient before discussing treatment with a third party, including the patient’s family members.

Reviewing and updating a patient’s medical history

A health history form can provide a dentist with a clear picture of the patient’s overall health status and current medications that should be taken into consideration when providing dental care. The form should include information about illnesses, medications, the patient’s primary care physician and an emergency contact. The form should also include an area for recording and updating any noted changes to a patient’s health status or medications. It is important that dental offices establish a system for collecting a current medical history. In this case, the office had not seen the patient for a year, yet they 354 M AY

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neglected to update his medical history prior to treatment. Had the patient’s medical history been updated to reflect recent medical issues or concerns, this problem could have potentially been avoided. Patients should review and update their health history form at every visit. The form should be signed and dated by both the patient and dentist to serve as evidence that the information is current and was discussed prior to treatment. When reviewing the health history with the patient, the dentist should follow up on information that seems incomplete, such as an indication of high blood pressure, but no medications are listed. Many patients, especially those who are elderly, may not remember certain medications or illnesses they have had until they are questioned. Asking openended questions, such as, “How are you feeling today?” may elicit this information. Any clarifications to the patient’s health history should be properly documented on the form along with the date of discussion. If the dentist believes there could be an undisclosed underlying health condition or information that the patient is unaware of or seems unclear about, they should send a Consultation Request for Dental Treatment Form to the patient’s physician, follow the physician’s recommendations and keep the physician’s response in the patient’s file. Occasional required changes to a health history form may be needed. Dentists should check with TDIC or their local dental society every two years to see if there are any changes to the health history form. Ensuring the safety and health of elderly patients requires several considerations, including their ability to understand treatment options, to provide a current medical history and to participate in the decision-making process. TDIC recommends the following when treating elderly patients:

Discuss future planning with the patient, the potential need for a caregiver and their long-term goals for their oral health. Documenting this information early will indicate what the patient cares about and help dentists avoid future problems. ■ Review and update health histories at every visit. ■ Evaluate the cognitive function of elderly patients using the four components of capacity: understanding, appreciation, rationalization and communication. ■ Emphasize the importance of preventive care. Prevention is important at every age to avoid premature tooth loss. ■ Create a senior-friendly environment and train staff on how to properly care for and interact with elderly patients. Consider limitations that elderly patients may have such as hearing loss or limited mobility and make the proper accommodations. ■ Dentists should not assume that just because a patient is older that they may not know what their needs and preferences are, and the patient’s age should not limit their treatment options. Be open to their preferences and be honest with them about the benefits, risks and costs of various treatment. These factors underscore the importance of dental providers to have clear and thorough communication practices to ensure treatment options align with the patient’s goals and values concerning their dental care. n ■

The Dentists Insurance Company’s Risk Management Advice Line is a benefit available at no cost to CDA members, as well as to policyholders protected by TDIC. To schedule a consultation, visit tdicinsurance.com/ RMconsult or call 800.733.0633.

Regulatory Compliance

C D A J O U R N A L , V O L 4 9 , Nº 5

Radiation Safety Checklist CDA Practice Support

wning and operating radiographic equipment requires compliance with safety rules enforced by the California Department of Public Health (CDPH) and, for those with practices located there, the radiation programs of Los Angeles and San Diego counties. This article summarizes the regulatory requirements for radiation safety.

Machine Registration

Owners of X-ray units must register them with the CDPH. The report or form completed by a vendor or distributor of X-ray equipment is not a registration form. Only the equipment owner may register it. Registration is site specific, so a change of address must be reported if a dental practice moves. Owners may use an online form on the CDPH website to register equipment and to report an address change, removal of equipment, change of ownership and practice closure. Owners are billed registration fees every two years. Dental practices in Los Angeles and San Diego counties also are required to submit shielding plan review documentation to their respective radiation program. A portable dental X-ray system cleared by the FDA and used in a manner consistent with that approval may be used in California. The unit should have a backscatter shield that is at least 0.25 mm lead equivalent and permanently affixed. The dental practice that owns and uses such units must have in possession a valid exemption letter from the CDPH (found on the CDPH website).

Regulations also require the machine operator to be behind a protective barrier (lead apron) during each exposure.

Operator Licenses or Certificates

An individual who operates radiographic equipment must have a license from the Dental Board of California and a certificate of completion from a board-approved radiation safety course or a board certificate indicating education equivalent to the boardapproved course.

Posted Notices

“Caution X-rays” signs must be posted where radiographs are taken. “Notice to Employees” (RH-2364) is included in the CDA-provided poster set. If the practice has received a notice or order related to radiological work, it must be posted along with any required response.

Dosimeters/Occupational Exposure Records

Records of occupational exposure to radiation must be kept and be made available to the CDPH upon request. Methods for developing these records include employee use of dosimeters and utilization of a health physicist. An exception to monitoring is allowed when it can be demonstrated that no employee is exposed to more than 10% of the maximum allowable annual dose, which is 5 rems. If the exception is met, monitoring should occur periodically to ensure that exposure does not exceed this amount and as long as no significant exposure is demonstrated or no radiographic equipment is changed.

An individual who uses a portable unit must wear a dosimeter, except for users of devices identified in the CDPH’s exemption letter. A declared pregnant employee who operates X-ray equipment should wear a dosimeter once the employer is notified of the pregnancy.

Written Safety Plan

Dental practices are required to have a written radiation safety program. The document should describe procedures and devices (engineering controls) that dental professionals use to ensure that occupational doses and doses to members of the public are as low as is reasonably achievable (ALARA principle). A CDA-provided template allows a dental practice to adopt the Radiation Safety Guide into its written program. The guide includes a copy of the state (Title 17) and federal (10 CFR 20) regulations applicable to dental practices. It summarizes standard practices and requirements in the following areas: ■ Responsibilities of the licensed dentist and radiographic machine registrant. ■ Requirements for dental radiographic machines. ■ Patient protection. ■ Responsibilities of dental personnel operating radiographic equipment. ■ Quality assurance and quality control. ■ Equipment quality assurance requirements. ■ Guidelines for prescribing radiographs. ■ Occupationally exposed women of childbearing age. ■ Protective barriers. M AY 2 0 2 1

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CDA Journal - May 2021: Oral and Maxillofacial Imaging

Articles inside

Tech Trends: A look into the latest dental and general technology on the market

Regulatory Compliance: Radiation Safety Checklist

RM Matters: Treating Elderly Patients: Minimize Risk With Informed Consent and Updated Health History

Findings in Oral Health: Attitudes and Quality of Life Among Patients Experiencing Homelessness

Development of an Interprofessional Education Event To Improve Dental and Pharmacy Students’ Attitudes Toward Interprofessional Collaboration

Oral Health Status of Children: Results of the 2018-2019 California Third Grade Smile Survey

Oral Health of California’s Children: A Commentary on the Status and Future Directions

Cone Beam Computed Tomography and Radiographs for Endodontics: A Pictorial Illustration of the AAE-AAOMR Position Statement

Effective and Safe Use of X-Rays: Understanding the Risks for Decision-Making

Applying the New ADA Quality Assurance Standard to Digital Intramural Radiographic Systems

Introduction: Oral and Maxillofacial Imaging: Evolving Technologies and Paradigm Shifts

Guest Editorial: Hope for a Cavity-Free Generation