Reference 43 Consultation Decision Analytic Protocol (DAP) to guide the assessment of Cone Beam CT for dental and craniofacial imaging May 2012 Table of Contents MSAC and PASC ..................................................................................................................................... 3 Purpose of this document.................................................................................................................. 3 Summary of matters for which PASC seeks input............................................................................. 4 Summary of matters for consideration by the applicant ................................................................. 4 Purpose of co-application ...................................................................................................................... 5 Background ............................................................................................................................................ 5 Current arrangements for public reimbursement ............................................................................. 5 Regulatory status ............................................................................................................................... 6 Intervention ........................................................................................................................................... 7 Description of technology ................................................................................................................. 7 Administration, dose, frequency of administration, duration of treatment ...................................... 7 Co-administered interventions .......................................................................................................... 8 Description of patient population ......................................................................................................... 9 Listing proposed and options for MSAC consideration........................................................................ 10 Proposed MBS listing ....................................................................................................................... 10 Clinical place for proposed intervention ............................................................................................. 11 Comparator .......................................................................................................................................... 16 Clinical claim ........................................................................................................................................ 16 Outcomes and health care resources affected by introduction of proposed intervention .............. 19 Outcomes ......................................................................................................................................... 19 Health care resources.......................................................................................................................... 20 Proposed structure of economic evaluation ....................................................................................... 22 Reference List ...................................................................................................................................... 27 Page 2 of 27 MSAC and PASC The Medical Services Advisory Committee (MSAC) is an independent expert committee appointed by the Minister for Health and Ageing (the Minister) to strengthen the role of evidence in health financing decisions in Australia. MSAC advises the Minister on the evidence relating to the safety, effectiveness, and cost-effectiveness of new and existing medical technologies and procedures and under what circumstances public funding should be supported. The Protocol Advisory Sub-Committee (PASC) is a standing sub-committee of MSAC. Its primary objective is the determination of protocols to guide clinical and economic assessments of medical interventions proposed for public funding. Purpose of this document This document is intended to provide a draft decision analytic protocol that will be used to guide the assessment of an intervention for a particular population of patients. The draft protocol will be finalised after inviting relevant stakeholders to provide input to the protocol. The final protocol will provide the basis for the assessment of the intervention. The protocol guiding the assessment of the health intervention has been developed using the widely accepted “PICO” approach (Richardson et al 1995). The PICO approach involves a clear articulation of the following aspects of the research question that the assessment is intended to answer: Patients – specification of the characteristics of the patients in whom the intervention is to be considered for use; Intervention – specification of the proposed intervention Comparator – specification of the current intervention most likely to be replaced by the proposed intervention Outcomes – specification of the health outcomes and the healthcare resources likely to be affected by the introduction of the proposed intervention Page 3 of 27 Summary of matters for which PASC seeks input The PASC invites comment on the following matters in respect to the proposed MBS descriptor: The proposed MBS descriptor does not currently include reference to the type of CBCT machine that would be eligible for reimbursement of CBCT items. It has been assumed that the designated 3D CBCT machines would be eligible; however PASC notes that there are other machines, often referred to as hybrid machines, which can be used to CBCT and seeks comment as to whether, or how, these should be addressed in relation to this item number. Does the current proposed MBS descriptor (page 11) cover the structures that would need imaging as part of the assessment and management of the clinical indications outlined in this review? Is a single fee (item) suitable or should differential rebates be considered to take into account the volume scanned and the time and expertise required for appropriate interpretation. Summary of matters for consideration by the applicant At the April 2012 PASC Meeting it was noted that further justification would be required if the proposed Cone Beam Computerised Tomography (CBCT) fee is higher than the current fee for a computer tomography (CT) scan. As such, further inputs may need to be provided to support the fee assessment. Given MBS fees directly affect the assessment of cost-effectiveness this matter should be resolved ahead of the development of the Final DAP. Page 4 of 27 Purpose of co-application A reference requesting consideration of Medicare Benefits Schedule (MBS) listing of Cone Beam Computerised Tomography (CBCT) for dental and craniofacial imaging was received by the Department of Health and Ageing (DOHA) in July 2010. A co-application requesting MBS listing of CBCT for 21 indications reimbursable through four separate MBS descriptors (sinus and facial bones; temporal bones, temporomandibular joint (TMJ) and internal acoustic meatus; dental and sleep apnoea) was submitted by Dental & Medical Diagnostic Imaging (DMDI) to the Department of Health and Ageing in March 2011. This Consultation Decision Analytic Protocol (DAP) is restricted to three indications (detailed below) which were identified as priority areas based on consultation with DOHA, the Royal Australian and New Zealand College of Radiologists (RANZCR) and the Australian and New Zealand Association of Oral and Maxillofacial Surgeons (ANZAOMS). These three indications also cover many of the 21 indications submitted by DMDI. Background Current arrangements for public reimbursement As part of the 2011-12 Budget, the Government announced that it would introduce an MBS interim item from July 2011 for CBCT. Prior to this, CBCT had been indirectly reimbursed through the MBS using a variety of combinations of item numbers for example: Diagnostic Imaging Services, Category 5, Group I3 - 60100 (tomography) in combination with x-ray items for the head and face (MBS items 57901 to 57945) and OPG MBS items (57960 to 57969) (Department of Health and Ageing & Megan Keaney 2011). Looking at the utilisation figures for the CBCT MBS Items 56025 and 56026, there were 12,871 attendances from 1 July 2011 to 30 September 2011, suggesting that CBCT is already widely used in clinical practice. Table 1 MBS Item for Cone Beam Computed Tomography (interim item) * From 1 July 2011 all services listed in the Diagnostic Imaging Services Table of the MBS, excluding Positron Emission Tomography services, preparation items 60918 and 60927 and MRI modifier items in subgroup 22, will have a mirror NK item (50% of the Schedule Fee) for diagnostic imaging services provided on aged equipment. This rule, known as ‘capital sensitivity’, is currently in place for CT and angiography and will be extended to improve the quality of diagnostic imaging services by encouraging providers to upgrade and replace aged equipment as appropriate. Page 5 of 27 Table 2 below details MBS utilisation for CBCT and associated procedures for the period April 2011September 2011. As can be seen, CT utilisation did not vary, however, the number of claims for tomography dropped substantially with the introduction of the CBCT item numbers in July 2011. While this supports the claim that other items such as MBS item 60100 were being used for CBCT, further data collection would be needed to confirm these trends. Table 2 MBS Utilisation for CBCT and associated procedures Regulatory status CBCT devices vary in terms of capabilities and image quality, and as such are listed accordingly on the Australian Register of Therapeutic Goods (ARTG). In the first group are those machines that are designated as 3D CBCT and these are registered as either for dental and medical imaging or for dental diagnostic imaging only (Hardman 2011). In a second group are those machines that are 3D or 2D reconstructed hybrid cone beam volumetric tomography with panoramic and cephalometric capabilities. These devices are included on the ARTG as panoramic tomography devices with a cephalometic capability for dental use. Similarly a third group includes hybrid machines that are included on the ARTG as panoramic tomography devices for dental use only (Hardman 2011). At the April PASC meeting it was noted that given this range of devices, it is important that the MBS descriptor specify the type of device that is eligible for reimbursement of CBCT items. Prior to July 2011, providers had been advised to register CBCT equipment as x-ray or orthopantomography equipment and claim corresponding items on the Diagnostic Imaging Services Table. Providers are now required to amend their location specific practice number to register (or reregister) CBCT equipment as CT (equipment code “GAN”). According to the applicant (DMDI), OPG devices are not included on the ARTG as CBCT machines, as the manufacturer has intended the device to be an orthopantomography (OPG) machine. For a manufacturer and sponsor to change their intended use of a device the CE certifications for the device and application to the Therapeutic Goods Administration (TGA) needs to be amended accordingly. Page 6 of 27 Intervention Description of technology CBCT is a method to acquire 3D images through the use of a rotating gantry to which an x-ray source and detector are fixed. In contrast to the fan shaped beams and multiple detectors used in multi-slice CT, CBCT uses a cone-shaped x-ray beam with a flat panel detector to acquire images. Software programs are applied to these image data to generate a 3D volumetric data set, which can be used to provide primary reconstruction images in multiple planes (axial, coronal, sagittal, oblique, curved) (White 2008). Hard structures such as teeth, jaws and skull are visualised well by CBCT due to isotropic and high spatial resolution. However, imaging of soft tissues is poor due to low contrast resolution, with the exception of the visualisation of soft tissue outlines such as the upper airway (Lapp et al 2008; White 2008). CBCT acquires all images in a single rotation with a scan time between 4.9 and 40 seconds. Some CBCT machines also allow the size of the irradiated area to be reduced through collimation of the primary x-ray beam thereby minimising the radiation dose to the patient. While CBCT is a radiological imaging technique with a range of potential indications, it is particularly suited to head, neck and dental applications and has primarily been used in this field. This DAP relates to the use of CBCT for the following indications: to assess bone quantity and quality as part of dental implant planning and in the management of suspected implant complications; to assess structures identified on two-dimensional radiographs as being in close approximation to sites of planned dento-alveolar surgery that may be at risk of damage during surgery; and for further assessment of the dentition and associated dento-alveolar and TMJ pathology which has not been adequately assessed using 2D radiographic techniques. Administration, dose, frequency of administration, duration of treatment CBCT units vary widely in size, cost, radiation dose and parameters such as the “field of view” (imaging volume). “Field of view” (FOV) refers to the scan volume of the CBCT device and depends on the size and shape of the unit, beam geometry and whether the beam is collimated (American Association of Endodontists & American Academy of Oral and Maxillofacial Radiology 2010). There is a close relationship between the FOV size and the radiation dose received by the patients, therefore it is important that the smallest FOV is selected for each patient to capture all the required clinical information. Small FOV scans also typically produce higher spatial resolution and increased scan quality due to a reduction in noise from scatter. Large field of view CBCT units are currently used in radiology practices and public hospital based dental units whereas smaller field of view CBCT units can be integrated into OPG units for use in private dental surgeries and radiology practices which typically are referred to as ‘hybrid’ units. Page 7 of 27 CBCT services are subject to the current professional supervision rules for CT, which state that the service must be performed under the professional supervision of a specialist in the specialty of diagnostic radiology who is available to monitor and influence the conduct of the examination, and to attend to the patient personally if necessary. Co-administered interventions Patients considered for CBCT would normally have had the following interventions a private dental consultation(s); intra-oral radiographs; and panoramic radiographs (OPG MBS item numbers 57959 - 57969) conducted by a suitably qualified health professional such as a radiologist. Page 8 of 27 Description of patient population Dental implant planning (including management of suspected complications) Dental implants are used to support dental restorations, such as prostheses, bridges and crowns, and are a treatment option for patients with missing teeth (Hobkirk et al 2003). Teeth loss can occur congenitally; due to dento-alveolar disease such as caries; teeth extraction for orthodontic treatment; or dental trauma (Hobkirk et al 2003; Roberts-Thomson & Do 2007). Dental implant treatment commonly involves two stages: (i) dental implant surgery - inserting a titanium or titanium alloy into the jawbone to replace the missing root of the teeth, and which then fuses (osseo-integrates) with the bone; and (ii) restorative procedures - after the implant has healed, prostheses or teeth replacements such as crowns and bridges may be inserted (Hobkirk et al 2003; Mitchell et al 2009). These procedures however may also be performed in a single stage depending on the clinical indication, with the provision of a temporary crown initially, and a permanent prosthesis upon satisfactory bone healing and osseo-integration of the implant. For patients with missing teeth for whom dental implants are the selected treatment option, CT or CBCT may be used to assist in pre-operative implant planning to assess the suitability of an implant site (sufficient height, density and width of bone), locate anatomy to avoid when placing the implant and determine the number, size and orientation of implants for optimal restorative results (White et al 2001). To assess structures at risk of damage during planned surgery Planned surgery includes removal of impacted teeth or wisdom teeth as well as other indications such as treatment of cleft palate. Dental impaction however, is one of the most common applications of CBCT. While most permanent teeth erupt into occlusion unassisted, some permanent teeth fail to erupt in the appropriate site in the dental arch. Third molars are the most frequently impacted teeth, followed by the permanent maxillary canines. In patients where the anatomy of the third molar is not extremely abnormal and the tooth in not correlated with the mandibular canal, surgery is not considered hazardous and further assessment is not needed. In patients with concerns in the lower third molar in which there is a relationship between the roots and the mandibular canal, a careful preoperative evaluation is needed. In such cases, CT or CBCT provides valuable information in addition to conventional radiographic techniques, potentially changing treatment to less invasive surgical intervention leading to fewer complications. Scope of surgical planning may also include apical surgery due to recurrent endodontic infection, root resection, periodontal surgery, bone grafts, surgery to remove bony or dental pathology. Assessment of the dentition and associated dento-alveolar, sinus and TMJ For some patients, clinical assessment indicates there is an underlying pathology, but radiographs do not provide information of relevance to patient management. This may be the case with indications Page 9 of 27 such as periodontal disease, dental inflammatory pathology associated with a non-vital tooth, anomalies of root anatomy and morphology, root resorption (internal and external), fractures, dislocations, ankylosis, disc displacement; inflammatory diseases leading to synovitis and capsulitis; arthritides; advanced degenerative disease; joint remodelling after diskectomy; and suspected disk displacement (Miracle & Mukherji 2009; White et al 2001). Due to cost and radiation dose, CT and CBCT may only be indicated for the diagnosis of conditions with complex bony abnormalities such as ankylosis, complex fractures and bony pathoses; if hard and soft tissue evaluation is required, as in the case of suspected disc displacement, Magnetic Resonance Imaging (MRI) is often the current method of choice (Brooks et al 1997). Listing proposed and options for MSAC consideration Proposed MBS listing DMDI has requested that CBCT be listed on the MBS under the proposed categories as shown in Table 3. Two additional categories were proposed by DIMI; one for temporal and skull base/ENT and another for sleep apnoea. These are not included here as they are not being reviewed as part of this assessment. DMDI have proposed that CBCT items be classified under Category 5 – Diagnostic imaging services: Group I2 – Computed Tomography under a new sub heading entitled ‘Cone Beam CT’. The fee proposed for each item is based on the sum of a combination of multiple x-ray codes (the practice undertaken prior to the introduction of the CBCT interim item) i.e. Dentomaxillofacial Imaging is proposed at $288.15 which is a combination of 57912, 57915, 57933, 60100 and 57901; Head and Neck is proposed at $336.80 (57903+57906+56022). Both proposed fees are more than the current MBS rebate for CBCT and more than the rebate offered for CT of facial bones (MBS 56022 $225.00). Further information will be needed to justify the higher fee. Table 3: Proposed MBS item descriptor for CBCT – Option 1 Page 10 of 27 In terms of the MBS descriptor, the TGA listing specifies that CBCT is approved for dental and medical diagnostic imaging, as opposed to specific indications within this category. Hence, while the MBS descriptors provided by DMDI are consistent with the TGA approved uses for Item, PASC agreed at its April 2012 meeting that one item descriptor should be developed for CBCT and this would cover the clinical questions intended for assessment as part of this review. The descriptor should also state that a patient can only have either a CT or CBCT and that both should not be undertaken on the one patient in the same region of the body in the same 12 month period. PASC also agreed that the item descriptor be limited to radiologists.. Accordingly table 4 outlines the revised wording for the proposed MBS CBCT items. Table 4 PASC determined MBS item descriptor for CBCT Clinical place for proposed intervention CBCT is being proposed in addition to two dimensional imaging (e.g. panoramic imaging) and as a replacement to CT. CBCT is being proposed in addition to 2D imaging where previously 2D imaging may have been used alone. CBCT offers more accurate and detailed imaging over that of 2D imaging. Patients however would be exposed to higher radiation doses than under 2D imaging alone. As a replacement for CT, CBCT would function as a direct substitute for currently subsidised CT and be used when lower dose conventional dental radiology cannot resolve the clinical questions. The key clinical claim associated with CBCT relative to CT is that it has superior safety and (at least) comparable effectiveness. As such, the expected impact of the introduction of CBCT on downstream and upstream parts of the management algorithm would be minimal. The above scenarios and below flowcharts are consistent with the principles outlined by SEDENTEXT for the use of CBCT in dental practice http://www.sedentexct.eu/content/basic-principles-use-dentalcone-beam-ct. Page 11 of 27 Figure 1 Management algorithm for planning of dental implants Figure 2 Management algorithm for the assessment of structures that are at risk of damage during planned surgery. Page 13 of 27 Figure 3 Management algorithm for the assessment of patients undergoing planned dento-alveolar surgery with a risk of injury (as diagnosed on prior imaging) Page 14 of 27 Figure 4 Management algorithm for the assessment of patients with suspected dento-alveolar, temporomandibular joint pathology which has not been adequately assessed using two-dimensional radiographic techniques. Page 15 of 27 Comparator CT has been used for dental and craniofacial imaging since its inception (White 2008). Multi detector CT uses a x-ray source that rotates around the patient while 16 to 64 detector rows acquire numerous thin ‘slices’, based on x-ray attenuation data, which are then stacked to construct images in numerous formats and planes, including 3D images (Boeddinghaus & Whyte 2008; Sukovic 2003). CT involves collimated fan shaped beams which take multiple thin slices in contrast to the single 3D cone shaped beam used in CBCT (Scarfe et al 2006). CT provides excellent bony detail but can also be used to assess craniofacial soft tissues (Boeddinghaus & Whyte 2008). CT equipment is large, expensive, and involves exposure to ionising radiation. OPG is an x-ray technique which provides a 2D image of the teeth and jaws. The x-ray tube or film rotate about the patient’s head and produce a flat image of the curved jaw surfaces (Boeddinghaus & Whyte 2006). It is one of the most common forms of radiographical techniques used in dental practice and involves low radiation exposure. The quality of images is variable as it may be influenced by patient positioning or movement of the patient, which can lead to magnification, distortion, superimposition of shadows and image artefacts (Boeddinghaus & Whyte 2006; Monsour & Dudhia 2008). While OPG is not a comparator to CBCT; CBCT is used in addition to OPG (see clinical algorithms above) and it is not intended to be used a replacement for OPG. Clinical claim The clinical claims for CBCT relative to its comparator(s) (2D imaging and CT) are listed below. Relative to 2D imaging, CBCT has the following potential benefits: Superior visualisation by providing images that are 3D and which have: ‐ high spatial resolution; ‐ 1:1 ratio requiring no magnification; and ‐ reduced image artifacts. Improved accuracy of diagnosis and assessment: Page 16 of 27 ‐ improve understanding of the anatomical site, nature and mechanism of pathology which may improve the ability to predict treatment success and select treatment, and thereby improve patient health outcomes; and ‐ improve planning for therapeutic procedures for dental implants (due to improved knowledge of the anatomical site and mechanism of pathology), which may lower complication rates for procedures and devices and re-intervention rates due to failed surgery or therapeutic devices. Relative to 2D imaging, CBCT has the following potential harms: substantially higher radiation dose. limited ability to accurately diagnose dental caries, especially around or adjacent to preexisting restorations, especially metallic restorations On the basis of the potential benefits and harms listed above, the key clinical claim associated with CBCT relative to 2D imaging is that it has superior effectiveness (benefit of 3D imaging) but is done at the cost of reduced safety. Relative to CT, CBCT has the following potential benefits: Exposes patients to lower radiation dependent on the type of machine used per use while providing at least equal (or nearly equal) image quality. Similar accuracy of diagnosis and assessment Equal or superior images of the bony pathology of the oral and facial structures: ‐ high spatial resolution; ‐ 1:1 ration requiring no magnification; and ‐ reduced image artifacts. Offer improved patient comfort: ‐ less claustrophobic; ‐ patient can be seated; and ‐ operator friendly. Be conducted through a less expensive and smaller machine. Relative to CT, CBCT has the following potential harms: poor contrast resolution of soft tissue; risk of repeat use due to use of multiple low field of view images for different regions; collimation of beam is too narrow, and hence pathology is missed. On the basis of the potential benefits and harms listed above, the key clinical claim associated with CBCT relative to CT is that it has superior safety and (at least) comparable effectiveness to CT (i.e minimal/no change in management). Hence, subject to the availability of data to populate a model, the type of economic evaluation required is a cost-effective analysis (CEA) or a cost-utility analysis (CUA) (the orange shaded box in). Page 17 of 27 Comparative safety versus comparator Table 5 Classification of an intervention for determination of economic evaluation to be presented Comparative effectiveness versus comparator Superior Non-inferior Inferior Net clinical benefit CEA/CUA Superior CEA/CUA CEA/CUA Neutral benefit CEA/CUA* Net harms None^ Non-inferior CEA/CUA CEA/CUA* None^ CEA/CUA Net clinical benefit None^ None^ Neutral benefit CEA/CUA* Net harms None^ Abbreviations: CEA = cost-effectiveness analysis; CUA = cost-utility analysis * May be reduced to cost-minimisation analysis. Cost-minimisation analysis should only be presented when the proposed service has been indisputably demonstrated to be no worse than its main comparator(s) in terms of both effectiveness and safety, so the difference between the service and the appropriate comparator can be reduced to a comparison of costs. In most cases, there will be some uncertainty around such a conclusion (i.e., the conclusion is often not indisputable). Therefore, when an assessment concludes that an intervention was no worse than a comparator, an assessment of the uncertainty around this conclusion should be provided by presentation of cost-effectiveness and/or cost-utility analyses. ^ No economic evaluation needs to be presented; MSAC is unlikely to recommend government subsidy of this intervention Inferior The key uncertainties surrounding the selection and implementation of the economic analysis include the following: Obtaining comparative effectiveness data to populate a CEA/CUA model. As CBCT is a relatively recent technology, there is likely to be limited evidence relating to its comparative effectiveness and much of the data may be in the form of case series or more technical papers rather in the context of a clinical study. To date, much of what has been published compares CBCT to OPG (replacement and incremental) rather than CBCT as a replacement to CT. Obtaining accurate safety data for the CEA/CUA. The lower radiation dose of CBCT relative to CT, and hence its superior safety, is one of the key clinical claims of CBCT. The safety assessment should (i) justify the use of the chosen indicator of radiation dosimetry, (ii) account for variations in radiation exposure that will occur based on the model of CBCT used and the field of view and (iii) account for utilisation factors which may influence lifetime radiation exposure and cost (see below). Estimating the utilisation of CBCT. Factors pertaining to the setting in which CBCT is used and its mode of operation which may influence its utilisation and hence its cost. For example: o whether the use of limited field of view CBCT encourages repeat usages, despite having a lower radiation exposure per dose. Page 18 of 27 Outcomes and health care resources affected by introduction of proposed intervention Outcomes The outcomes to be considered in the proposed assessment of CBCT versus its comparators (are listed below: Planning of dental implants Management of dental implants Safety Safety Radiation dose Radiation dose Adverse events Adverse events Diagnostic accuracy Sensitivity Specificity Additional TP & FP Diagnostic accuracy Sensitivity Specificity Additional TP & FP Change of Management Re-implantation/revision surgery Change of Management Re-implantation Heath Outcomes Osseointegration tooth survival/restoration quality of life Heath Outcomes Osseointegration tooth survival/restoration Surgical morbidity Dental function Quality of life Assessment of patients undergoing planned dento-alveolar surgery with an increased risk of injury Safety Radiation dose Adverse evens Diagnostic accuracy Sensitivity Specificity Additional TP & FP Change of management: % of treatment plans changed Surgical procedures avoided Health outcomes Surgical morbidity Avoidance of nerve injury Avoidance of sinus perforation Alleviation of pain Periodontal healing Dental function Quality of life Assessment of patients with suspected TMJ or dento-alveolar pathology Safety Radiation dose Adverse events associated with subsequent surgery or treatment Diagnostic accuracy Sensitivity Specificity Additional TP & FP ROC Change of management: % of treatment plans changed Surgical procedures avoided Health outcomes Restored jaw function Alleviation of oro-facial pain Quality of life Health care resources Expected impact of the introduction of CBCT on the use of associated interventions The use of CBCT in patients who previously would have undergone 2D imaging alone will result in an increase in costs in the diagnostic phase of the indications, however, if CBCT enables more effective diagnosis and assessment then this may be offset by a reduction of costs associated with the treatment and management of adverse effects and re-intervention following failed treatment. As a replacement to CT; prior diagnostic imaging and consultations leading up to the use of CBCT and dental procedures performed after CBCT are likely to remain the same after the introduction of CBCT, but may be done more safely (with less radiation exposure). However, as above, if CBCT enables more effective diagnosis and assessment relative to its comparators, then this may lead to a reduction of adverse effects and re-intervention following failed treatment and a change in the utilisation of the health care resources used to treat or manage these complications. Page 20 of 27 Table 6: List of resources to be considered in the economic analysis Page 21 of 27 Proposed structure of economic evaluation The following questions are being proposed: to assess bone quantity and quality as part of dental implant planning and in management of suspected implant complications; to assess structures identified on 2D radiographs as being in close approximation to sites of planned dento-alveolar surgery that may be at risk of damage during surgery; and further assessment of the dentition and associated dento-alveolar and TMJ pathology which has not been adequately assessed using two-dimensional radiographic techniques. Assessment of bone quantity and quality as part of dental implant planning and in management of potential implant complications. In this scenario it is proposed that the main benefits of CBCT as an addition to 2D imaging will be a reduction in complications through the provision of more accurate/detailed imaging in regards to bone quantity and quality leading to better osseointegration and patient outcomes but with an increase exposure to radiation. As a replacement for CT, patient outcomes should be similar but with a reduction in radiation exposure. Table 7 PICO to define the research question for the assessment of bone quantity and quality as part of dental implant planning. Page 22 of 27 Table 8 PICO to define the research question for the assessment of bone quantity and quality as part of the management of suspected implant complications. Figure 5 Simplified decision tree structure for the assessment of bone quantity and quality as part of dental implant planning and in the management of suspected implant complications Please note that the decision trees given here are provided for the purposes of supplementing the information given in the PICO tables and clinical algorithms and may not reflect the cost-effectiveness models required in the final assessment Page 23 of 27 Assessment of structures identified on 2D radiographs as being in close approximation to sites of planned dento-alveolar surgery that may be at risk of damage during surgery In this scenario, it is proposed that the main benefit of CBCT as an addition to 2D imaging will be a reduction in surgical morbidity (e.g. avoidance of nerve injury) through the provision of more accurate/detailed imaging but with an increase exposure to radiation. As a replacement for CT patient outcomes should be similar but with a reduction in radiation exposure. Table 9 PICO to define the research question for the assessment of patients undergoing planned dento-alveolar surgery with an increase risk of injury as diagnosed on prior imaging Page 24 of 27 Figure 6 Simplified decision tree structure for the assessment of patients undergoing planned surgery with an increase risk of injury as diagnosed on prior imaging Please note that the decision trees given here are provided for the purposes of supplementing the information given in the PICO tables and clinical algorithms and may not reflect the cost-effectiveness models required in the final assessment Assessment of the dentition and associated dento-alveolar and temporomandibular joint pathology which has not been adequately assessed using 2D radiographic techniques. In this scenario, it is proposed that the main benefit of CBCT as an addition to 2D imaging will be a more accurate diagnosis (e.g. avoidance of unnecessary treatment) through the provision of more detailed imaging but with an increase exposure to radiation. As a replacement to CT it is assumed that outcomes should be similar but with a benefit of reduced radiation exposure for those undergoing CBCT. Table 10 PICO to define the research question for the assessment of the dentition and associated dento-alveolar, or temporomandibular joint pathology which has not been adequately assessed using two-dimensional radiographic techniques. Page 25 of 27 Decision options/clinical research questions: What is the safety, effectiveness and cost-effectiveness of CBCT in addition to two dimensional imaging for the assessment of symptomatic patients with suspected TMJ or dento-alveolar pathology on clinical assessment who have undergone prior imaging? What is the safety, effectiveness and cost-effectiveness of CBCT compared with CT for the assessment of symptomatic patients with suspected TMJ or dento-alveolar pathology on clinical assessment who have undergone prior imaging? Figure 7 Simplified decision tree structure for the assessment of the dentition and associated dento-alveolar or temporomandibular joint pathology which has not been adequately assessed using two-dimensional radiographic techniques. Please note that the decision trees given here are provided for the purposes of supplementing the information given in the PICO tables and clinical algorithms and may not reflect the cost-effectiveness models required in the final assessment Page 26 of 27 Reference List 1. American Association of Endodontists , American Academy of Oral and Maxillofacial Radiology 2010, Joint position statement on the use of Cone-Beam Computed Tomography in Endodontics [Internet]. Available from: 29 March 2011]. 2. Boeddinghaus, R and Whyte, A 2006. 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Miracle, AC and Mukherji, SK 1-8-2009. Conebeam CT of the Head and Neck, Part 2: Clinical Applications, American Journal of Neuroradiology, 30 (7), 1285-1292. 10. Mitchell, L, Mitchell, Det al 2009, Oxford Handbook of Clinical Dentistry, 5th edition, New York: Oxford University Press. 11. Monsour, PA and Dudhia, R 2008. Implant radiography and radiology, Australian Dental Journal, 53 (Suppl-25. 12. Richardson, WS, Wilson, MC et al 1995. The well-built clinical question: a key to evidence-based decisions, ACP Journal Club, 123 (3), A12-A13. 13. Roberts-Thomson, K and Do, L 2007, Chapter 5, Oral health status. Australia's dental generations: The national survey of Adult oral health 2004-06, AIHW cat. no. DEN 165. Canberra: Australian Institute of Health and Welfare. 14. Scarfe, WC, Farman, AG et al 2006. Clinical applications of cone-beam computed tomography in dental practice, Journal (Canadian Dental Association), 72 (1), 75-80. 15. Sukovic, P 2003. Cone beam computed tomography in craniofacial imaging, Orthodontics & Craniofacial Research, 6 (Suppl-6. 16. White, SC 2008. Cone-beam imaging in dentistry, Health Physics, 95 (5), 628-637. 17. White, SC, Heslop, EW et al 2001. Parameters of radiologic care: An official report of the American Academy of Oral and Maxillofacial Radiology, Oral Surgery Oral Medicine Oral Pathology Oral Radiology & Endodontics, 91 (5), 498-511. Page 27 of 27