READERS' FORUM
Letters to the editor*
Orthodontic imaging: The future is now
he special article, “Clinical considerations and poten-
T tial liability associated with the use of ionizing radia-
tion in orthodontics” (Abdelkarim A, Jerrold L. Am J
Orthod Dentofacial Orthop 2018;154:15-25), provides a
considerable amount of information regarding the risks,
benefits, imaging selection criteria, and timing (before,
progress, final) of radiographic imaging in orthodontics.
The advantages and limitations of various imaging tech-
niques are discussed in detail. The references are
numerous, and “the process of prescribing radiographs
in orthodontics” is summed up succinctly as being “based
on the practitioner's clinical judgment for a particular pa-
tient's presentation, and the ALARA directive—keeping
radiation as low as reasonably achievable.”
In discussing “initial radiographic acquisition in or-
thodontics,” the authors stated that “the combination
of pretreatment panoramic and cephalometric radio-
graphs appears to be appropriate and sufficient in most
cases.” There is also a lengthy discussion regarding the
use of CBCT imaging, with the authors stating that
“although the benefits of CBCT in orthodontics cannot
be ignored, the orthodontist must be able to justify that
CBCT images bring a benefit to the patient over what
can be obtained via 2D imaging.” This need for justifica-
tion appears to be related to the assertation that “for most
CBCT examinations, the effective radiation doses are
greater than those for conventional radiographic tech-
niques.” How then would the authors' recommendations
regarding CBCT change if a practitioner chose to use
CBCT scans for all radiographic acquisitions with effective
radiation doses equal to or less than those for conven-
tional 2D radiographic techniques?
In late 2013, the current generation of CBCT scan-
ners—the so called “ultralow dose scanners” (ULD)—
became available in the dental marketplace in the United
States. By limiting the field of view (FOV) and managing
voxel size and scan time (ULD settings), the dentition can
be imaged in 3 dimensions at an effective dose of
5.3 mSv.1 A larger FOV (16 3 13 cm) additionally capable
of producing reformatted panoramic and cephalometric
views (lateral and anteroposterior views for most patients)
has an effective dose of 11.4 mSv.1 These effective dose
levels compare favorably with, and in many cases are
less than, the 2D panoramic and cephalometric effective
* The viewpoints expressed are solely those of the author(s) and do not reflect
those of the editor(s), publisher(s), or Association.
doses noted in the article's Table I. Also, in Table I, the au-
thors provided effective doses for CBCT imaging. The
CBCT imaging effective dose range stated is 20 to
1025 mSv. The low-end effective dose stated in the Table
is not accurate when current generation CBCT scanners
are used with ULD parameters.1 When considering the
effective dose of other 2D imaging options, particularly
if ectopic teeth are suspected, ULD CBCT should be
considered the imaging option of choice.2,3
There are important considerations when CBCT im-
aging is used in orthodontic practice, and the authors
have reviewed many of these in detail. I would like to
add a few more points.
1. CBCT scanners are versatile, allowing the practi-
tioner to select a specific FOV and resolution for
each patient's diagnostic needs. Simplistically,
smaller FOVs and ULD settings expose the patient
to lower effective doses. Larger FOVs and higher res-
olution settings can significantly increase effective
doses. Regarding these selectable parameters, the
ALARA and the ALADA (as low as diagnostically
acceptable) concepts must be adhered to.4 Ortho-
dontic radiographic acquisition using ULD CBCT
scanning protocols adheres to both principles.
2. Older CBCT scanners manufactured before the intro-
duction of ULD CBCT technology (pre-2013) typi-
cally cannot acquire similar FOV images at effective
dose levels that are less than those of 2D digital
panoramic or cephalometric technology.5 Risk and
benefit factors (ALARA) must be considered when us-
ing older CBCT scanners (also an important consider-
ation with older 2D imaging technology). When
researching the use of CBCT technology in orthodon-
tics, it must also be understood that any articles pub-
lished in, or before late, 2013 (or citing references
before 2013) evaluated CBCT scanners manufactured
before the availability of ULD scanning protocols.
Many recommendations for CBCT scanning in ortho-
dontics in the older literature are based on higher
effective dose exposures and the ALARA (risk/benefit)
directive. The American Dental Association's Council
on Scientific Affairs advisory statement on “The use
of cone beam computed tomography in dentistry
(American Dental Association Council on Scientific
Affairs. J Am Dent Assoc 2012;143:899-902)” and
the American Academy of Oral and Maxillofacial Ra-
diology's “Clinical recommendations regarding use
of CBCT in orthodontics. Position statement by the
749
750
American Academy of Oral and Maxillofacial Radi-
ology” (this position statement is now deemed
invalid, as is has not been re-approved in the 5 year
period since first published) (American Academy of
Oral and Maxillofacial Radiology. Clinical recommen-
dations regarding use of cone beam computed
tomography in orthodontics. [corrected]. Position
statement by the American Academy of Oral and
Maxillofacial Radiology. Oral Surg Oral Med Oral
Pathol Oral Radiol 2013;116:238-257) are 2 such
publications. Updated studies with recommendations
based on the use of ULD CBCT technology vs 2D
radiographic techniques would be beneficial.
3. CBCT scans with lower effective doses (ULD) inher-
ently have lower resolution and thus lower image
quality than higher resolution scans. Although
high-resolution scans may be required for certain
periodontic, endodontic, or oral surgical proced-
ures, the quality of ULD CBCT scans is diagnostically
acceptable for orthodontic purposes (ALADA) and is
improving as the technology advances.6
4. Concerns over the interpretation of CBCT scans
taken for orthodontic diagnostic purposes continue,
and the authors have reviewed these in detail. The
interpretation of intraoral radiographs has been
included in dental school curricula for more than
half a century. Today, the interpretation of digital
2D intraoral and panoramic radiographs is taught
in dental school. The interpretation and analysis of
cephalometric radiographs (lateral and anteroposte-
rior) are taught in our orthodontic residencies. At the
2017 American Association of Orthodontists' Winter
Conference in Fort Lauderdale, Chris Bentson re-
ported on a survey of recent (2016) orthodontic res-
idency graduates in the United States: 88%
responded that they had used CBCT imaging for
diagnosis and treatment planning during their resi-
dencies. In my opinion, as ULD CBCT imaging be-
comes more common in orthodontics, just as it has
become more common in orthodontic residency pro-
grams, the interpretation and analysis of CBCT scans
must become part of orthodontic residency curricula.
The availability of continuing education courses on
this subject must also increase. Dental education
has evolved with advances in technology, and the ed-
ucation in our specialty must evolve as well.
The authors' conclusions are well thought out and
concise. I agree with them fully, with 1 exception. “4.
Consider CBCT imaging only when it is expected to yield
a benefit to the patient or change the outcome of treat-
ment over 2D radiographs.” When exposure protocols
(FOV, voxel size, scan time) are tailored to diagnostic needs,
December 2018  Vol 154  Issue 6 American Journal of Orthodontics and Dentofacial Orthopedics
Readers' forum
the current generation of ULD CBCT scanners can provide
an immediate benefit—more diagnostic information with
an effective dose equal to or less than 2D radiographs.
My conclusion would be that CBCT imaging is acceptable
for radiographic acquisition when its effective dose is less
than or equal to comparable FOV 2D radiographs, or
when it is expected to yield a benefit to the patient or
change the outcome of treatment over 2D radiographs.
Kenneth Webb
Westboro, Mass
Am J Orthod Dentofacial Orthop 2018;154:749–50
0889-5406/$36.00
Ó 2018 by the American Association of Orthodontists. All rights reserved.
http://dx.doi.org/10.1016/j.ajodo.2018.09.003
The author completed and submitted the ICMJE Form for Disclosure
of Potential Conflicts of Interest, and none were reported.
REFERENCES
1. Ludlow JB, Walker C. Assessment of phantom dosimetry and image
quality of i-CAT FLX cone-beam computed tomography. Am J Or-
thod Dentofacial Orthop 2013;144:802-17.
2. Ludlow JB, Davies-Ludlow LE, White SC. Patient risk related to com-
mon dental radiographic examinations: the impact of 2007 Interna-
tional Commission on Radiological Protection recommendations
regarding dose calculation. J Am Dent Assoc 2008;139:1237-43.
3. Isaacson KG, Thom AR, Atack NE, Horner K, Whaites E. Orthodontic ra-
diographs: guidelines for the use of radiographs in clinical orthodontics.
4th ed. London, United Kingdom: British Orthodontic Society; 2015.
4. Jaju PP, Jaju SP. Cone-beam computed tomography: time to move
from ALARA to ALADA. Imaging Sci Dent 2015;45:263-5.
5. Ludlow JB, Timothy R, Walker C, Hunter R, Benavides E,
Samuelson DB, et al. Effective dose of dental CBCT-a meta analysis
of published data and additional data for nine CBCT units. Dento-
maxillofac Radiol 2014;44:20140197.
6. Ludlow JB, Koivisto J. Dosimetry of orthodontic diagnostic FOVs using
low dose CBCT protocol. Available at: www.researchgate.net/
publication/273635877_Dosimetry_of_Orthodon0c_Diagnos0c_FOVs_
Using_Low_Dose_CBCT_protocol. Accessed September 7, 2018.
Authors' response
W e thank Dr Webb for his comments on our article
(Abdelkarim A, Jerrold L. Clinical considerations
and potential liability associated with the use of ionizing
radiation in orthodontics. Am J Orthod Dentofacial Or-
thop 2018;154:15-25). Because his was a very detailed
and well-supported opinion, we felt the need to respond
in kind. As we mentioned in our original article, we must
stress again that there are no legally binding statutes,
rules, or regulations that provide explicit radiographic
prescription protocols for orthodontic practice. Howev-
er, there are guidelines for the appropriate and defen-
sible use of ionizing radiation in orthodontics.
Regarding Dr Webb's question about cone-beam
computed tomography (CBCT), if a practitioner chooses