CT Scans: Standard of Care for Implants?

Jeffrey, a dentist, asks:
I have been reviewing the blogs here on CT Scans for dental implants, and I’m just wondering if a CT scan was easy to get and read, would you do it more often when treatment planning for dental implants?

Personally, I have been using a service called Facial Imaging and find it very useful. Do we all think that this will become the “standard of care” for documentation, if and when it does become easier to use and more available? If that happens, will we all need cone beam technology in our offices? Won’t this then make dental implant treatments even more expensive to patients? Would appreciate any comments that will help elucidate the future direction of implant therapy.

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49 thoughts on “CT Scans: Standard of Care for Implants?

  1. There have been many reasons put forward by dentists for NOT getting CT scans before implant treatment – 1. Radiation dose: This is now as low as 2-3 panoral films yet the information gained is vastly more useful. 2. Cost: If a patient can afford to have an implant placed, they can afford to have it placed by a dentist who has the information they need to place it safely and usefully. 3. Access to scans: Volumetric (Cone Beam) scanners are now more and more affordable and are therefore becoming more plentiful.

    Do you need a CT scan for every implant case? Of course not – but when they are safe, cheap and easily accessible you’d be a fool not to get one for complex cases or where the ususal fun anatomical structures are close to the proposed implant site.

    Will it make implant treatment more expensive? When I get a scan for a complex case, I often get a Simplant-planned drilling guide (Surgiguide) made from it. This vastly reduces the surgical time (the most expensive part of implant treatment) and makes the restorative phase faster (implants exactly in the right place) and that allows me to pass this saving onto the patient in a reduced fee.

    Everyone wins!

    Kind Regards from the UK.

    Bill Schaeffer

  2. I couldn’t agree with Dr. Schaeffer more. The radiation dose far exceeds the potential risk of surgical complications without a CT Scan, especially in the complex cases where treatment planning is very important. The scans are so advanced now, that a scout panorex is performed and a CT Scan is done only in the area where the implant is performed further reducing radiation. And unlike traditional radiographs, there is no magnification factor so true measurement can be made off the scan itself. Fortunately, I’m in a large metro-city with many options of obtaining a scan in not a huge inconveinence.

    They are not the standard of care for every implant case. But I consider it a standard of care when treatment planning complex cases such as multiple implants in the posterior mandible, to obtain more accurate information. But in other cases, I want what’s best for my patients, even if it does cost the 200-300 dollars for a scan, its piece of mind and accurate treatment planning. Also gives the patient visual evidence of the limitations of treatment with their anatomy. Its an educational and treatment planning tool.

  3. there is no doubt that the CT scan provides more information than intra oral films and the clinical examination. to never use one is as wrong as always using it. in cases were there are adjacent teeth or the sites have previously been grafted, there is no real need for it. Like everything we do in the profession, there is a time and place, indication and contraindiction for everything.

  4. CBCT (Cone Beam CT) is a powerful tool, however it needs to be coupled with a implant placement program (i.e. Simplant) to be really useful. Certainly nerve tracks can be drawn out and avoided using these programs and getting a Surgiguide for precise placement of this implant is golden. I do not think a CBCT by itself is that illuminating if you cannot visualize the implant placement.

  5. By the way, Rhonda numbness after implant did you go to a surgeon who is using Simplant and have a CBCT done prior to implant placement? Did you have a comprehensive neurologic exam and a microsurgery consult after the numbness occurred?

  6. I can tell you about a recent case that was botched by one of our colleagues because no conventional treatment planning was done. Teeth #7-10 had been lost in this 30 something female during childhood. The O.S. did not use surgical guides to place in the #7 and 10 positions. I now have simplant in the office and we discovered after imaging, facial and lingual dehiscences of both implants were noted. Discussion with the implant manufacturer confirmed that failure was imminent and the implants would need to be removed, the ridge repaired and then see if the implants could be placed anew. The case came from one of my top referrals who recieved the case as a teaser to refer more from a local O.S. The GP was not comfortable with the placement. Prior to Simplant, we thought only #8 and 9 implants were needed, not a major redo. Simplant is not yet the standard of care, but for complex cases, you can’t afford not to use it. CT Scans are more costly and the radiation exposure is significant, but in this case, a straightforward case has turned into a complex one and may have compromised any sort of hope for a normal result. The more you plan and the more data you have to do it, the better the case. Just be open-minded and use the technology when appropriate.

  7. “discussion with the implant manufacturer confirmed that failure was imminent and the implants would need to be removed” – I have to ask, how does this involve the manufacturer? I would far rather have fenestrated implants restored and monitored for theoretical bone loss than have someone trephine them out.

  8. Why would anyone contact the “implant manufacturer” to determine if an implant is failing or not. That is something a competant surgeon can determine. The manufacturer just sells implants and drills. I agree that a “fenestrated” implant is not necessarily something that must be removed. It should be observed. It really bothers me when I hear so-called professionals use terms like “botched” when discussing their colleagues. If you weren’t there at the time of surgery or have not discussed directly with the surgeon then you have no right to be so critical. Sometimes one is forced to place an implant in a position that is not “ideal” due to bone quality, even though we all strive for perfection.

  9. CT scans are a valuable aid in implant dentistry. They are indicated whenever they will help provide a better treatment outcome for your patient, ie, more accurate implant placement or reducing risks such as nerve injury. The days of “exploratory surgery” are over. CT scans let you know what to expect before you do surgery. They not only give you 3D information, but also allow you to do virtual treatment planning and obtain computer generated surgical guides when used with software such as NobelProcera, Simplant, VIP, etc.
    Medical CT scanners are the gold standard in medicine regarding clarity and accuracy for bone imaging. The newer scanners can complete a scan of the maxilla or mandible in a few seconds. This reduces artifacts from patient movement during a scan. These new scanners have much less radiation thasn the original single slice CT scanners

  10. Contacting the manufacturer determined that the necessary 60Ncm required to sustain the prosthesis by having enough bone support was not achieved as 80% bone loss around the implant provides only 12Ncm of sustainable force which would not be sufficient to support the prosthesis. I am disappointed with hostility in this blog. Obviously, the manufacturer would not be able to determine the stability of the implant, but they would be able to provide the criteria required to sustain a successful prosthesis. Would you prefer to place a prosthesis that was destined to fail? If the simplant imaging was not used, we would have never known. The assumption would have been that the implant were placed in sound bone. Do you think we are idiots? Ignorance is no excuse, especially now that we have the data to know otherwise. If you saw the 3-d image, trephination may not even be required. That’s how poorly planned the case was. In this circumstance, the fact that standards of care were not followed, yes, with all do respect, I and the restoring dentist do feel the case was botched. A simple device such as a bone caliper would have indicated that a 4.5mm implant could not have been placed in 6.0mm of bone. When the first implant failed, the ridge could have possibly been repaired before placing a larger diameter implant that is now dehisced not fenestrated through the bone. I wish you could see the image. I have bent over backwards to help prevent a potentially litigious situation. If you do enough work, we can see failures and should see failures. The important thing here is to learn from them. By the G.P.s report, he had not been consulted regarding surgical guides or diagnostic wax-ups. I myself have had cases even with guides that did not wind up ideal. When a case with guides goes off-track slightly, the question remains, how far off-track would they have gone otherwise. My reason for responding in the first place was to stress the importance of being open to all the tools available and understand that we are part of a greater community that can share ideas. BTW, the O.S. offered to remove the implants as well. I believe that better planning good have helped this case. Who knows, maybe I am wrong, too. Again, it would be great if you could see the images to assess for yourself.

  11. If you can send your patient for a ct scan, the imaging center should be able to provide you with a CDrom disk and you can manipulate the image on your computer(they put a reader program on the disk). We use iCat scanning for more than half of our cases. The more you use it, the more it seems silly to place any implants without this information. In a rural setting, I can understand problems with access though.
    I do not think it’s “standard of care”, but it’s a super nice piece of data for your case planning.

  12. A simple device such as a bone caliper would have indicated that a 4.5mm implant could not have been placed in 6.0mm of bone. When the first implant failed, the ridge could have possibly been repaired before placing a larger diameter implant that is now dehisced not fenestrated through the bone. I wish you could see the image.

    In response to this, If the lingual plate is intact this case may be retreatable. If the implants are removed with a trephine though, there will probably not be any bone left for a bone graft. Maybe some thought should be given to putting these implants “to sleep” to preserve this ridge?

  13. The definition of an expert is someone from experience and training can help their patient and others to provide a level of service that help their patients and follow docs. That is of course my defintion. After over 2000 implants I realize that the more information I have, the better off the patient is and the “expertly” I can help the patient. The other thing is that as soon as I think something is going to be routine…watch out. So my original question of CAT Scan or cone beam as the standard (lawyers out of the picture) seems to be correct. The price is cheap.
    I had 2 done on Friday for 1000 bucks and each case is over 10,000 dollars. With the right information… the right diagnosis and then the right treatment.

  14. Remember the principle of the Seven P’s.

    Prior Proper Planning Prevents Piss Poor Performance.

    CBCT and Simplant can help with prior proper planning and should be utilized in complex cases especially if vital structures are near or if there is a question of adequate bone support then this technology removes the uncertainty. Often a ridge covered with soft tissue will be thinner beneath and a treatment plan must take this into account.

  15. I own an i-CAT CBCT scanner, imaging facility, in Manchester New Hampshire. It has been a real benefit to the Dentists and patients in the area. The diacom information is read by a radiologist and the liability of reading the volume is not on the referring Dentist. I do have the Simplant Master, all cases (if the Dentist has Simplant Planner) are put on Simplant, if not then i-CAT Vision software, and films along with the reading is provided.
    If you are going to read the case make sure it is not from the reformatted (i.e. simplant)information!

  16. Dear Advanced Dental Imaging, I am sure that the docs in your area are very greatful for the imaging services you provide them along with the readings. does your company reformat diacom images into simplant planner? what is the cost? I will contact you in an e-mail regarding this, thank you

  17. With the advent of the CBCT scan machines, the last true barrier has fallen… we can now take a scan in the office. But we still need to be able to read and interpret the images in the scan data – whether through SIM/Plant or VIP, or other software applications.

    Regardless if you use a nearby medical CT facility or your own scanner, it is the most important tool for us to appreciate the patient’s anatomy. The interactive software applications allow us to plan the case prior to touching the patient… the information helps remove the guesswork from what we do. There are plenty of educational opportunities which will help provide clinicians with the knowledge they need to keep up with the technological advances that 3-D imaging provides us. I am very happy to see that so many are finally embracing this technology. So beware of a two dimensional mind-set, in a three dimensional world! Go to http://www.simplantacademy.com for more information on upcoming courses, or seek them out at the ICOI, AO, AAID, AAOMS or other organizations which offer pre-confrence hands-on courses.

  18. An Oral Radiologist is the ONLY Doctor that should read a CT!

    WHAT UTTER NONSENSE – do you read panorals? Do you read pariapicals? Do you read occlusals and cephs?

    A CT is just another x-ray. Does it take some time and training to get used to reading panorals? Of course it does, and reading a CT is no different.

    If you don’t want to read a CT, that’s fine. But don’t suggest that only an oral radiologist can read one – that’s like saying only an endodontist can do a root canal.

    Regards,

    Bill Schaeffer

  19. do you read from diacom information? do you look to read for carotid stenosis? medical pathology? well, that is what your CT includes!

  20. “Do you read from DICOM information?”

    DICOM stands for Digital Imaging and Communications in Medicine. All it is is a data standard.

    You can read that format using whatever program you want. Even the radiologists don’t read plain data (sounds like Neo in the Matrix!) they use a viewer program too.

    “Do you look for carotid stenosis? Medical pathology?”

    The answer is, of course I do – but I tend to see more carotid stenosis on panorals than from CTs anyway. Do you look for this on your Panorals? – of course you do and it’s no different with a CT.

    Look, if you think a dental radiologist should read you CTs, then they probably should.
    They would probably be better than you at it.

    But then you should porbably also get a medical radiologist to read it as well for the medical pathology that might be there because they would be better at that than a dental radiologist.

    And whilst you’re at it, get them to check out your PAs and panorals too – because let’s face it, none of us really remembers what ALL those lines are on a panoral.

    And you still really shouldn’t be doing root canals if an endodontist could fill the canal better! etc. etc………

    If you are placing implants then you MUST know the regional anatomy. If you know the anatomy, you should be able to read a CT (especially with the 3D modelling available now). If not, you shouldn’t be placing the implants in the first place.

    But PLEASE don’t say that only an endodontist can do a root canal – sorry – only a dental radiologist can read a CT

    Kind Regards,

    Bill Schaeffer

  21. Dear last poster (no name),

    As a lawyer, you may not be aware that dentists are trained in more than just teeth.

    Facial anatomy and both regional and general pathology are also included in the undergraduate syllabus.

    Any postgraduate studies will obviously re-inforce that.

    Kind Regards,

    Bill Schaeffer

  22. For the past year and a half, we haved used a NewTom 3G for our implant cases. Volumetric imaging has been an invaluable tool for pre-treatment planning. It helps me to determine if we can place an implant in the site, place an implant and simultaneously graft, or graft prior to implant placement. It shows interarch relationships using virtual modeling. But what it does NOT do is to translate knowledge of anatomy into surgical reality. Unless you are willing to use CAD milled surgical guides or use surgical navigation (i.e. RoboDent), your placement of implants is still determined by your surgical skill. It has very little to do with survival tables or enhanced osseointegration. What IS important, in an era of having to meet the aesthetic paradigm, is exquisite implant placement so that the implant is indistinguishable from the tooth it is replacing. I don’t care if someone has placed 10,000 implants without an untoward consequence. It will be the one case where you have perforated the buccal/lingual plates, have a severe bleeding episode, violate the neurovascular bundle, peroforate a sinus, touch an adjacent tooth, or MISS additional anatomy like a bifurcated mandibular canal, deinnervate the synphysis by severing the incisive canal, or miss pathology that you will find yourself in a very difficult defense. Put yourself in the patients perspective. Would you want a surgeon doing implant surgery on you using a PA, Panorex, or DVT? There IS a changing standard of care whether you like it or not. There is a CT on virtually every street corner and an increasing number of focused cone beam DVT machines available. It is my opinion that the use of DVT imaging will become as commonplace as the use of pans today. There is simply no logical excuse to avoid the use this technology.

  23. Being a patient who had a greedy ,speedy periodontist rush to place an implant, after first telling me my bone graft should wait 2 months before placing implant that perfed the sinus wall, and 10 days later exited through my nose. I had complete opacification that required sinus surgery. I would have welcomed the i-Cat cone beam CT, the small cost of the CT would have saved me quite alot of money and I almost lost my life due to infection, after being on antibotics for 8 months now. I feel that the cone beam should be standard of care, it takes alot of the guess work out when placing the implant. I recommend it to anyone getting an implant. I would welcome any questions anyone has for me reqarding my horrible implant experience.

  24. kb, if I understand correctly, the bone graft perforated your sinus membrane and got scattered all around and some exited through your nose and unfortunately the whole thing got infected and you have been on antibiotics for 8 months! Did you have your sinus cleaned out via a separate surgery? That should have prevented the infection. It is not high-tech imaging that is going to prevent complications like this. As you have pointed out, more likely human greed and speed caused it.All the advantages of high tech imaging techniques will come to nought when confronted with the said greed and speed. I rely on optimal technology that is available where I am that is within the affordability of the people I am serving.An OPG or even a PA is sufficient at times when used together with my trusty palpating finger and eyeballs and a sound grasp of jaw anatomy and bone physiology. And definitely, I have to refrain from falling under the spell of greed and speed.Learnt it from a few close shaves! kb, I hope you recover soon and do not give up hope. A dental implant is still the best replacement for a lost tooth. Find someone who will take the time and care to do it properly with a conscientous clinical skill. Cheers.

  25. Is there a textbook (imaging bible) anyone would highly recommend on dental cone-beam imaging???

    regards from Australia

  26. “# Anonymous Says:
    September 26th, 2006 at 8:19 am

    Dear SF OMS: Rhonda “Numbness after Implant” is still waiting for your advice. Thank you.”

    I could use some helpful advice in this area too.

  27. Who should you go to to receive the cone beam or a sophisticated x-ray. I had a root canal 9 days ago and have been in severe pain ever since. The dentist took a x-ray and said it looked good but prescribed anti-biotics.

  28. “Is there a textbook (imaging bible) anyone would highly recommend on dental cone-beam imaging???”

    Danny,
    Check out Quintessence Publishing’s Dental Applications of Computerized Tomography: Surgical Planning for Implant Placement – by Stephen Rothman.
    Also, if you’ve never been to NYC, you should consider coming up in July. July 13-14 there will be a 3-D Imaging Symposium that will be most interesting and informative. I don’t know what the weather is like in Australia in July, but it is a perfect time to visit NY. If you want more information, let me know.

    3-D imaging is only the first step in improving the quality of the implant treatment we deliver. Ultimately it should be coupled with a CAD/CAM milled surgical guide to be able to easily and accurately transfer the surgical plan to the mouth. For that Simplant is an excellent program which has stood the test of time, but requires you to use an imaging center that is a “Simplant Master Site” to process your scans. VIP from Implant Logic is a newer, simpler program, which is “self processing” thus allowing you to use any CT or CBVT. I have an i-CAT and several of the local dentists who refer to me use VIP software and ILS stents (implantlogic.com). They have excellent customer service and an impressive turn around time for scan applicances and surgical guides. They will hold your hand throughout the process if you need it.

  29. Anyone using CoDiagnostix treatment planning software? Any pros or cons to this system compared to the others on the market?

  30. This an answer to Danny’s question about CBCT books.
    There are currently no books dealing with CBCT imaging (and applications exclusively). The book metioned earlier (Quintessence) discusses the dental applications of medical imaging.
    I ma aware that there are works in progress on writing a dedicated CBCT imaging book for ther dental field.
    Be patient anbd keep checking.

    C

  31. There are several books which address the potential pathology found in CBCT.
    Good example are case by case reviews of the significant findings commonly found with each disease.
    However, the subtleties of disease are detected only when compared to a norm established by review of countless cases in head and neck radiology.
    The role of diagnostic radiologists in the review of all tissues included in studies, such as CBCT, cannot be overstated.

  32. As the director of a scan center in South Florida (AdvanScan), virtually all of the referrals we get from dentists are to assess bone volume, trajectory, and density prior to implant placement. We have only had a single patient referred for pathology, and it ended up being a condyloma. This was diagnosed by an OMFR. The only other referrals we in turn make is when there is a potential for pathology that we pick up secondarily. In my opinion, there is no need for routine referral to OMFR, but, if you are not going to refer, you must take time to adequately review each scan.

  33. As a Marketing man for an Imaging center what would be the best approach for marketing the new Simplant software? What are the selling points that would convince you to send to my imaging center, based on the Simplant software alone?

  34. Related to Jeffrey’s original posting regarding “Standard of Care” of CT for implant planning, we could probably use some definition. I discovered the following, which I think is appropriate. By this definition, it seems that CT-based planning for all or defined implant cases will become a “standard” when a majority of experts with similar training and experience agree.

    Definition: Physicians are bound by a standard of care which holds a doctor responsible for administering sufficient treatment during any medical procedure. By definition, the standard of care is the degree of competence that a physician is expected to demonstrate. A doctor should execute procedures at the same reasonable level of efficiency that another competent physician with similar training and experience would consider satisfactory.

    The standard of care does not necessarily require a physician to utilize the most expensive or most advanced procedures, only that he provides care that would be comparable to a similarly trained doctor under related circumstances. For example, a family practice physician would not testify against a neurosurgeon about violations of the standard of care. Another neurosurgeon with the same experience level would be called in to give testimony.

    In the vast majority of the United States, the standard of care is a national policy, not a local one. A physician in California is bound by the same standard of care as a similarly trained doctor in Maine. The standard of care covers all levels of treatment – from the administering of proper medications based on Food and Drug Administration and Physicians Desk Reference recommendations to performing open-heart surgery. If a physician violates the standard of care, a negligence claim may be filed.

  35. Todd, well put. There seems to be some interest in applying the latest and greatest tecnnology as the new standard of care. Reasonable treatment protocol does not require the latest and greatest. Thank you for your comments. They should be heeded by all. Bill

  36. Cone Beam Volumetric Tomography is the future of implant dentistry. I believe it will be the standard of care eventually. After 20 years of placing dental implants we purchased a CBVT unit for our Suwanee, GA group practice and are using it for all of our dental implant cases as well as our complex oral surgical extraction of impactions, TMJ cases and while I probably would not initially take a CBVT scan for a single root canal, I would be interested in the details of the pulp chamber anatomy in a case I already had a CBVT scan on. Cost of CBVT is not an issue if you have had a few implant failures that you could have prevented with a little more foreknowledge that the CBVT scan can give.

  37. In implant dentistry,the clinical significance of the accuracy of the measurements will depend on the level of accuracy required. If the data from CT are used for pre-surgical planning, sufficiently accurate CT information will prevent surgical inaccuracies leading to potential complications, which may require additional surgery. Accurate CT data make surgery more precise and predictable and allow the clinician to accurately plan treatment and evaluate surgical outcomes. The more complex the surgery, the more critical it is to have accurate CT data to minimize intra-operative risk and poor outcome. The acceptable degree of error will depend on the type and complexity of the surgical procedures being planned and the goals of the study. Computed tomography provides clinicians with the ability to investigate the inner depths of the human anatomy slice by slice through computer reformation of radiographic images. In the modern medical CT, the x-ray source rotates within the gantry chamber that houses the x-ray tube and detector, while the patient is being moved through the gantry on the bed. This method of CT scanning is known as helical CT. As radiation has a cumulative effect on the human body, any reduction in exposure to radiation is considered beneficial. With the recent introduction of cone-beam CT (CBCT) specifically designed for the volumetric imaging of the maxillofacial area, the radiation dose to the patient has been significantly reduced. The CBCT uses a single 360° rotation of the x-ray tube around the head to acquire the images instead of several rotations as in conventional medical spiral CT. This effectively reduces the exposure time and simultaneously the absorbed radiation to the patient. Regardless of the type of CT used, the images produced by the CT method allow better localization of the anatomical structures than conventional two dimensional radiographs, which are often geometrically distorted and plagued by bilateral structural superimpositions.

  38. We must be careful of what we wish for. A young dentist starting out has costs of running an office paying his huge student loan, living in a house and affording a car. Add a digital CT and he or she might as well work for a clinic. The companies that make these machines need to make them more affordable so that we can get them in each and every office. Furthermore, it is good to have a CT but it is what you do with it that is the test. Scans taken at a remote location usually give you a printed copy that looks nice but does not give you an exact idea of clinical position. A surgical stent made prior with barium sulfate can give you a better idea of your area of concern. It is also goodto have the reader software DICOM to be able to manipulate the image. All of the pretty advetising pictures of the CT companies only come if you have the software to do this. Simplant is about 5,000.00. This puts addition “salt in the financial wound” of a young dentist.

  39. Bottom line:
    The patient has been exposed to radiation. The information is there and it should ALL be evaluated. Be it by a radiologist or the ordering doc.
    Look at the temporal bones, the internal auditory canals, the paransal sinuses, intra-orbital contents, oropharyngeal soft tissues, vasculature, TMJs etc… If there is early disease on the study, ie temporal bone epitympanic cholesteatoma and you can see, you might just save that persons hearing.
    In diagnostic radiology we see an enourmous amount of “incidentalomas” that were picked up on a CT, MR, US, plain film that had nothing to do with why the patient got the imaging. The disease will be there. Its just a question of catching and identifying it.
    There is alot of info contained in a CBCT

    Dan Reidman, DO

  40. My husband is a Periodontist and we recently purchased an ICat machine for our office. We had a patient that saw him for an implant consult, upon taking the scan my husband noticed blockage in the patient’s carotid artery and referred her to a Cardiologist. This patient underwent surgery within days of the scan and we were told he saved her life.

    My question is, although the scans are taken in our office for solely “dental” purposes, is there some type of consent form that is needed for patients’ to sign that states this? The whole head is scanned, so legally what is the right thing to do here? Not everything is going to be so clear when scans are being read for dental reasons, not medical? We do not want to be held liable for anything medical when the patient doesn’t have any previous mentioned medical problems.

    Any feedback would be helpful.

  41. Tara,

    To answer your question, you can have a waiver form, but likely most courts will not uphold it. Especially if it’s something serious. Safest thing to do is be well prepared, you can do that by referring the scan to a radiologist. You can include it as part of the scan fee. We are getting a cone beam CT machine in my office and every scan will cost around 300, 100 of it going to the radiologist to read the scan for incidentals. It is amazing the amount of information available in a cone beam CT and the amount that can be missed. I thought I had it down till I discussed a case with a radiologist. Changed my perspective on things quite a bit.

    Mo

  42. Ist Point: The standard of care is not national it is a local issue (state, county) second point: CBCT will not be the standard of care until it is cost effective for every dentist to have one and be able to evaluate pathology like a radiologist. Even a surgeon or other physician uses said reports along with their other clinical findings and radiologist are not always right. third point if implant dentist knew how to place blades and subs they would not need to as many cbct. 4th point; if docs would take soundings, palpate and knew their surgical anatomy of the area of interest they would not need a cbct. We are getting lazy.

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