Guidelines for oral and maxillofacial imaging: COVID-19 considerations
2020; Elsevier BV; Volume: 131; Issue: 1 Linguagem: Inglês
10.1016/j.oooo.2020.10.017
ISSN2212-4411
AutoresDavid MacDonald, Dan Colosi, Mel Mupparapu, Vandana Kumar, Werner H. Shintaku, Mansur Ahmad,
Tópico(s)COVID-19 diagnosis using AI
ResumoSevere acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the virus causing the current coronavirus disease 2019 (COVID-19) pandemic, is not only highly infectious but can induce serious outcomes in vulnerable individuals including dental patients and dental health care personnel (DHCPs). Responses to COVID-19 have been published by the Centers for Disease Control and Prevention and the American Dental Association, but a more specific response is required for the safe practice of oral and maxillofacial radiology. We aim to review the current knowledge of how the disease threatens patients and DHCPs and how to determine which patients are likely to be SARS-CoV-2 infected; consider how the use of personal protective equipment and infection control measures based on current best practices and science can reduce the risk of disease transmission during radiologic procedures; and examine how intraoral radiography, with its potentially greater risk of spreading the disease, might be replaced by extraoral radiographic techniques for certain diagnostic tasks. This is complemented by a flowchart that can be displayed in all dental offices. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the virus causing the current coronavirus disease 2019 (COVID-19) pandemic, is not only highly infectious but can induce serious outcomes in vulnerable individuals including dental patients and dental health care personnel (DHCPs). Responses to COVID-19 have been published by the Centers for Disease Control and Prevention and the American Dental Association, but a more specific response is required for the safe practice of oral and maxillofacial radiology. We aim to review the current knowledge of how the disease threatens patients and DHCPs and how to determine which patients are likely to be SARS-CoV-2 infected; consider how the use of personal protective equipment and infection control measures based on current best practices and science can reduce the risk of disease transmission during radiologic procedures; and examine how intraoral radiography, with its potentially greater risk of spreading the disease, might be replaced by extraoral radiographic techniques for certain diagnostic tasks. This is complemented by a flowchart that can be displayed in all dental offices. Statement of Clinical RelevanceThe practice of oral and maxillofacial radiology has been severely constrained by the current COVID-19 pandemic. An infection control strategy based on current best practices and science and the use of extraoral in place of intraoral imaging techniques are discussed. The practice of oral and maxillofacial radiology has been severely constrained by the current COVID-19 pandemic. An infection control strategy based on current best practices and science and the use of extraoral in place of intraoral imaging techniques are discussed. Although aerosols and airborne contamination are created by commonly used dental equipment such as ultrasonic scalers, high-speed dental handpieces, air/water syringes, air polishing, and air abrasion,1Centers for Disease Control and Prevention. Guidance for dental settings. https://www.cdc.gov/coronavirus/2019-ncov/hcp/dental-settings.html. Accessed September 29, 2020.Google Scholar techniques used in oral and maxillofacial radiology (OMR), particularly intraoral radiography, can also produce aerosols. The control or reduction of such aerosol-generating procedures is a principal strategy in the global response to the current coronavirus disease 2019 (COVID-19) pandemic.1Centers for Disease Control and Prevention. Guidance for dental settings. https://www.cdc.gov/coronavirus/2019-ncov/hcp/dental-settings.html. Accessed September 29, 2020.Google Scholar As dental health care personnel (DHCPs) return to practice following the prolonged lockdown provoked by this pandemic, they encounter an entirely changed world, requiring new systems of work. The American Dental Association (ADA) has fully adopted the Centers for Disease Control and Prevention (CDC) recommendations and applied them to almost every aspect of dental care in its "Return to Work Interim Guidance Toolkit,"2Mupparapu M. Dental practitioners' role in the assessment and containment of coronavirus disease (COVID-19): evolving recommendations from the centers for disease control.Quintessence Int. 2020; 51: 349-350PubMed Google Scholar,3American Dental Association. Return to work toolkit. https://www.google.com/search?client=firefox-b-d&q=ada±return±to±work±toolkit. Accessed September 29, 2020.Google Scholar but the guidelines are still limited with regards to radiography. Although the first peer-reviewed report on this matter reflected the widespread confinement of radiography to extraoral projections4Meng L. Hua F. Bian Z. Coronavirus disease 2019 (COVID-19): emerging and future challenges for dental and oral medicine.J Dent Res. 2020; 99: 481-487Crossref PubMed Scopus (1100) Google Scholar because of the possible production of an aerosol by coughing and gagging during intraoral radiography, a letter to the editor advised the appropriate use of intraoral radiography when necessary.5Dave M. Coulthard P. Patel N. Seoudi N. Horner K. Letter to the editor: use of dental radiography in the COVID-19 pandemic.J Dent Res. 2020; 395: 1257Google Scholar The death of a dental colleague in March due to COVID-19 reverberated throughout the dental world. The CDC COVID-19 response team reported that 37% of health care workers who died were 65 years of age and over.6Centers for Disease Control and PreventionCOVID-19 response team. Characteristics of health care personnel with COVID-19—United States, February 12-April 9, 2020.MMWR Morb Mortal Wkly Rep. 2020; 69: 477-481Crossref PubMed Scopus (570) Google Scholar Furthermore, males, those with underlying health conditions, and those of minority ethnicities are particularly vulnerable to developing COVID-19 symptoms and, more important, developing a severe outcome, which includes death (Table I).7Guzik T.J. Mohiddin S.A. Dimarco A. et al.COVID-19 and the cardiovascular system: Implications for risk assessment, diagnosis, and treatment options.Cardiovasc Res. 2020; 116: 1666-1687Crossref PubMed Scopus (997) Google Scholar,8Strain W.D., Jankowski J., Davies A. et al. Development of an objective risk stratification tool to facilitate workplace assessments of healthcare workers when dealing with the COVID-19 pandemic. https://www.medrxiv.org/content/10.1101/2020.05. 05.20091967v3. Accessed September 29, 2020.Google Scholar In the absence of a widely-used vaccine of proven efficacy, identification of our vulnerable colleagues is a priority.Table IConditions that render dental health care personnel vulnerable to COVID-19VulnerabilityDetailsAgeEach decade from the 50s carries almost a doubled risk of deathSex at birthMales are at least twice as likely to die of COVID-19Underlying conditionsDiabetes (either type 1 or 2) poses an increased risk, even more so in complicated casesObesity, particularly if the body mass index exceeds 35Cardiovascular disease, namely, angina, previous myocardial infarction, stroke, or other cardiac intervention; for example, bypass or pacemaker surgery. Note. Heart failure further enhances that riskPulmonary disease, including asthmaMalignancy, where patients with active disease are more vulnerable over those in remissionRheumatic diseasesImmunosuppressant treatment.EthnicityFront-line health care personnel from ethnic minorities are more likely to die than their Caucasian counterpartsMain sources: Guzik et al.7Guzik T.J. Mohiddin S.A. Dimarco A. et al.COVID-19 and the cardiovascular system: Implications for risk assessment, diagnosis, and treatment options.Cardiovasc Res. 2020; 116: 1666-1687Crossref PubMed Scopus (997) Google Scholar and Strain et al.8Strain W.D., Jankowski J., Davies A. et al. Development of an objective risk stratification tool to facilitate workplace assessments of healthcare workers when dealing with the COVID-19 pandemic. https://www.medrxiv.org/content/10.1101/2020.05. 05.20091967v3. Accessed September 29, 2020.Google Scholar Open table in a new tab Main sources: Guzik et al.7Guzik T.J. Mohiddin S.A. Dimarco A. et al.COVID-19 and the cardiovascular system: Implications for risk assessment, diagnosis, and treatment options.Cardiovasc Res. 2020; 116: 1666-1687Crossref PubMed Scopus (997) Google Scholar and Strain et al.8Strain W.D., Jankowski J., Davies A. et al. Development of an objective risk stratification tool to facilitate workplace assessments of healthcare workers when dealing with the COVID-19 pandemic. https://www.medrxiv.org/content/10.1101/2020.05. 05.20091967v3. Accessed September 29, 2020.Google Scholar The purpose of this article is to (1) review the background of the COVID-19 pandemic and what is currently known about this disease, including signs and symptoms of infection and mechanisms of transmission; (2) list tactics with which DHCPs can minimize the risk of transmission of the disease between themselves and patients, with emphasis on preparing radiology equipment and accessories; and (3) consider how the prescription of radiographic techniques might be changed to provide the desired diagnostic information with minimal risk. The CDC defines DHCPs as "all paid and unpaid persons serving in dental healthcare settings who have the potential for direct or indirect exposure to patients or infectious materials, including: Body substances, contaminated medical supplies, equipment, surfaces and air."1Centers for Disease Control and Prevention. Guidance for dental settings. https://www.cdc.gov/coronavirus/2019-ncov/hcp/dental-settings.html. Accessed September 29, 2020.Google Scholar SARS-CoV-2 spreads "through direct, indirect, or close contact with infected people through infected secretions such as saliva and respiratory secretions or their respiratory droplets, which are expelled when an infected person coughs, sneezes, talks or sings. Respiratory droplets are >5-10μm in diameter whereas droplts ≤5μm in diamater are referred to as droplet nuclei or aerosols."9World Health Organization. Transmission of SARS-CoV-2:implications for infection prevention precautions. https://www.who.int/news-room/commentaries/detail/transmission-of-sars-cov-2-implications-for-infection-prevention-precautions. Accessed November 14, 2020.Google Scholar An aerosol (an abbreviation of aero-solution), is a suspension of fine solid particles or liquid droplets in air or another gas.10https://www.merriam-webster.com/dictionary/aerosol. Accessed June 22, 2020.Google Scholar "The virus has been shown to persist in aerosols for hours, and on some surfaces for days under laboratory conditions."1Centers for Disease Control and Prevention. Guidance for dental settings. https://www.cdc.gov/coronavirus/2019-ncov/hcp/dental-settings.html. Accessed September 29, 2020.Google Scholar Death results not only from acute respiratory distress syndrome but also from organ failure.11Cecconi M. Forni G. Mantovani A. Ten things we learned about COVID-19.Intensive Care Med. 2020; 46: 1590-1593Crossref PubMed Scopus (27) Google Scholar The main signs and symptoms of COVID-19 are fever or chills, cough, shortness of breath or difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, congestion or runny nose, nausea, vomiting, and diarrhea.12Centers for Disease Control and Prevention. Symptoms of COVID-19. https://www.cdc.gov/coronavirus/2019-ncov/symptoms-testing/symptoms.html. Accessed September 29, 2020.Google Scholar Identification of these manifestations in patients who are entering the clinic for radiographs permits the dentist to accomplish the first decision point in patient management: whether or not the patient has or is being investigated for this disease (Figure 1). It distinguishes between 2 separate groups of patients: those with or suspected of having COVID-19 and those with no evidence or suspicion of the disease. This is the point where the dentist will decide to modify his or her radiographic activities ("Yes" in the decision tree) or proceed as normal ("No" in the decision tree). The early and prompt detection and isolation of patients diagnosed with or suspected of having COVID-19 is advised in order to minimize exposure of colleagues and other patients.13Mossa-Basha M. Meltzer C.C. Kim D.C. Tuite M.J. Kolli K.P. Tan B.S. Radiology department preparedness for COVID-19: radiology scientific expert panel.Radiology. 2020; 296: E106-E112Crossref PubMed Scopus (224) Google Scholar However, the CDC warns that "COVID-19 may be spread by people who do not show symptoms."12Centers for Disease Control and Prevention. Symptoms of COVID-19. https://www.cdc.gov/coronavirus/2019-ncov/symptoms-testing/symptoms.html. Accessed September 29, 2020.Google Scholar Considering the nature and presentation of the disease and the possibly serious outcomes for those infected with the virus, DHCPs should institute a clearly defined regimen to reduce the risk of transmission, as stated in Table II. The table is derived from the CDC's updated "Guidance for Dental Settings."1Centers for Disease Control and Prevention. Guidance for dental settings. https://www.cdc.gov/coronavirus/2019-ncov/hcp/dental-settings.html. Accessed September 29, 2020.Google Scholar In the first instance, a colleague developing the above signs and symptoms should not report for work or, if developing them in the office, should be sent home or to another destination specified by state or local health departments. Immediate emergency medical attention should be sought if a colleague or patient displays the following signs: trouble breathing, persistent pain or pressure in the chest, new confusion, inability to wake up or stay awake, and bluish lips or face.12Centers for Disease Control and Prevention. Symptoms of COVID-19. https://www.cdc.gov/coronavirus/2019-ncov/symptoms-testing/symptoms.html. Accessed September 29, 2020.Google Scholar Because this list is not exhaustive, any other severe clinical manifestation should, of course, provoke similar urgency.12Centers for Disease Control and Prevention. Symptoms of COVID-19. https://www.cdc.gov/coronavirus/2019-ncov/symptoms-testing/symptoms.html. Accessed September 29, 2020.Google ScholarTable IIGeneral steps to be taken by dental office personnel during the COVID-19 pandemicStagesElementsActivity/activitiesPreparatoryPre-patient care education and training of DHCPs and other staffEducation and training on prevention of transmission of SARS-CoV-2Identify vulnerable colleagues (Table I)Appropriate use of PPE to prevent contamination of clothing, skin, and the environment during the process of doffing the equipmentMaintain proper PPE EPA-standard suppliesUnderstand the office's PPE and EPA-standard inventory and its utilization and supply rates because these directly affect the degree and continuity of dental services providedSignageThe acquisition and/or production and appropriate siting of such signage to facilitate the correct conduct of all DHCPs, patients, and visitors within the dental officeWaiting roomRemove magazines, coffee machines, toys, and other frequently touched materialsArrange furniture in waiting area to ensure social/physical distancingTriage and physical admission of patient to the officeTeledentistry and triage protocols to be applied to the patients before presentingTelephone screen patients for COVID-19Telephone triage to determine whether patients need to be seen in a dental settingAdvise patients to minimize the number of accompanying visitors and inform them that all must wear face masks/covering and will be subject to screening for fever and symptomsPhysical (in-person) screening and triage of patients at entry into the dental officeEnsure that everyone complies with respiratory hygiene (wear face masks/coverings) and applied cough etiquette and hand hygiene (ABHR)Take temperature (fever is equal to or greater than 100°F)Inquire as to whether the patient has already been asked to self-quarantineInstall physical barriers at reception areasDirect COVID-19-confirmed or suspected patients to the operatory for their emergency treatment and NOT to the waiting roomOperatoryAvoid or minimize aerosol-generating proceduresAerosol-generating procedures are commonly created in dentistry by ultrasonic scalers and high-speed dental handpieces, air/water syringes, and air polishing and abrasion, but also by patients when gagging and/or resisting intraoral radiography and by children Figure 1 and Table IIIAirborne infection isolation roomsSingle-patient rooms at negative pressure relative to surrounding areas with a minimum of 6 air changes/hour.*Air changes per hour: the ratio of the volume of air flowing through a space in a certain period of time (the airflow rate) to the volume of that space (the room volume). This ratio is expressed as the number of air changes per hour. The operatory door should be closed except upon entry. Exhaust air directly to the outside or filtered through a HEPA filterHEPA positioningShould be close to the patient's head but NOT such that any DHCP gets between it and the patient. This is relevant when the DHCP is placing intraoral sensors in the mouthAfter the patient has left"DHCP should ensure that environmental cleaning and disinfection procedures are followed consistently and correctly after each patient."1Centers for Disease Control and Prevention. Guidance for dental settings. https://www.cdc.gov/coronavirus/2019-ncov/hcp/dental-settings.html. Accessed September 29, 2020.Google ScholarUse the appropriate EPA-standard cleaning materials. See Table IVDHCP, dental health care personnel; PPE, personal protective equipment; EPA, Environmental Protection Agency; ABHR, alcohol-based hand rub; HEPA, high-efficiency particulate air. Air changes per hour: the ratio of the volume of air flowing through a space in a certain period of time (the airflow rate) to the volume of that space (the room volume). This ratio is expressed as the number of air changes per hour. Open table in a new tab DHCP, dental health care personnel; PPE, personal protective equipment; EPA, Environmental Protection Agency; ABHR, alcohol-based hand rub; HEPA, high-efficiency particulate air. Each DHCP should be educated in how SARS-CoV-2 can infect people and be trained in and have practiced the appropriate use of personal protective equipment (PPE) before caring for patients. Further details included in recent CDC documentation1Centers for Disease Control and Prevention. Guidance for dental settings. https://www.cdc.gov/coronavirus/2019-ncov/hcp/dental-settings.html. Accessed September 29, 2020.Google Scholar,14Centers for Disease Control and Prevention. Interim infection prevention and control recommendations for healthcare personnel during the coronavirus disease 2019 (COVID-19) pandemic. https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html. Accessed September 29, 2020.Google Scholar are summarized in Table II.•To protect patients and co-workers, DHCPs should wear a face mask at all times while they are in a health care facility because this offers both source control and protection from exposure to splashes and sprays of infectious material from others.•DHCPs working in areas with minimal to no community transmission should continue to use eye protection or an N95 or higher-level respirator. Universal use of a face mask for source control is recommended for DHCPs.•The DHCP in charge or the dental office owner should ensure that PPE of the appropriate quality (e.g., N95 or higher-level respirators, disposable-after-single-use isolation gowns) is available for the clinical team in the proper quantities. Face cloths are not PPE and should not be used in the care of COVID-19 (or suspected) patients. Other PPE includes protective eyewear. Because the gaps between the glasses and the face do not protect the eyes from all splashes, sprays, and aerosols, face shields are required to guard against them.14Centers for Disease Control and Prevention. Interim infection prevention and control recommendations for healthcare personnel during the coronavirus disease 2019 (COVID-19) pandemic. https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html. Accessed September 29, 2020.Google Scholar•A separate system of work will need to be created for radiographic procedures, which includes patient preparation, observing time intervals between patients, and cleaning and decontamination after the patient has departed from the facility. In addition to ensuring that all DHCPs have the required PPE and are utilizing it properly, it is important to consider the PPE requirements for patients who have or are suspected of having COVID-19 to manage the risk these patients pose to the dentist and clinical team members who receive all patients (emergency and nonemergency) in the dental office (Table II).•If emergency dental care is medically necessary for a patient who has or is suspected of having COVID-19, the DHCP should follow the CDC's interim document for health care settings.14Centers for Disease Control and Prevention. Interim infection prevention and control recommendations for healthcare personnel during the coronavirus disease 2019 (COVID-19) pandemic. https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html. Accessed September 29, 2020.Google Scholar In such a setting, patients should wear all recommended PPE including a face mask or cloth face covering to contain secretions and should be covered with a clean sheet.•After arrival at their destination, the receiving radiology personnel and the transporter (if assisting with transfer) should perform hand hygiene and wear all recommended PPE. The potential for asymptomatic SARS-CoV-2 transmission underscores the importance of applying prevention practices to all patients, including social distancing, hand hygiene, surface decontamination, and having patients wear a cloth face covering or face mask while in a health care facility. •DHCPs should limit clinical care to one patient at a time whenever possible.•Set up operatories so that only the clean or sterile supplies and instruments needed for the dental procedure are readily accessible. Any supplies and equipment that are exposed but not used during the procedure should be considered contaminated and should be disposed of or reprocessed properly after completion of the procedure.•A limited amount of evidence exists regarding the clinical effectiveness of preprocedural mouth rinses before intraoral radiography to reduce aerosol generation and thereby SARS-CoV-2 transmission. There is some evidence, however, that whereas ethanol-based preprocedural mouth rinses (perhaps with essential oils) reduce the viral load, chlorhexidine does not. Povidone-iodine and hydrogen peroxide show some promise.15Kelly N. Nic Íomhair A. McKenna G. Can oral rinses play a role in preventing transmission of COVID 19 infection?.Evid Based Dent. 2020; 21: 42-43Crossref PubMed Scopus (21) Google Scholar Nevertheless, it must be appreciated that "there is currently insufficient high-quality evidence to suggest that oral rinses are effective against SARS-CoV-2."15Kelly N. Nic Íomhair A. McKenna G. Can oral rinses play a role in preventing transmission of COVID 19 infection?.Evid Based Dent. 2020; 21: 42-43Crossref PubMed Scopus (21) Google Scholar Therefore, oral rinses should not be used as alternatives to high-quality PPE and rigorous infection control.15Kelly N. Nic Íomhair A. McKenna G. Can oral rinses play a role in preventing transmission of COVID 19 infection?.Evid Based Dent. 2020; 21: 42-43Crossref PubMed Scopus (21) Google Scholar In light of COVID-19, the ADA has provided interim guidance for DHCPs, recommending the avoidance or reduction of intraoral radiography during the COVID-19 crisis.16American Dental Association. Interim guidance. https://www.ada.org/en/publications/ada-news/2020-archive/april/ada-releases-interimguidance-on-minimizing-covid-19-transmission-risk-when-treating-emergencies. Accessed September 29, 2020.Google Scholar As mentioned earlier, the virus can persist for long periods of time in aerosols. A potential source of aerosol production in intraoral radiography is gagging and coughing. In one study, the overall frequency of gagging during intraoral radiography was 13% but the frequency differed significantly between patients radiographed by trained radiographers (frequency of 9%) and by students (frequency of 26%).17Sewerin I. Gagging in dental radiography.Oral Surg Oral Med Oral Pathol. 1984; 58: 725-728Abstract Full Text PDF PubMed Scopus (14) Google Scholar Although gagging occurred when positioning intraoral receptors in all sites, the most common site was the maxillary molar area.17Sewerin I. Gagging in dental radiography.Oral Surg Oral Med Oral Pathol. 1984; 58: 725-728Abstract Full Text PDF PubMed Scopus (14) Google Scholar Recommendations of the ADA for radiographic prescription for common dental tasks (selection criteria) were first published in 1982; the most recent guidelines appeared in 2012.18American Dental Association. Dental radiographic examinations: recommendations for patient selection and limiting radiation dose. https://www.fda.gov/radiationemitting-products/medical-x-ray-imaging/ada-fda-guide-patient-selection-dentalradiographs. Accessed September 29, 2020.Google Scholar The broad thrust of these recommendations is still pertinent in the COVID-19 era; the prescription of every radiograph must arise from a particular clinical indication.18American Dental Association. Dental radiographic examinations: recommendations for patient selection and limiting radiation dose. https://www.fda.gov/radiationemitting-products/medical-x-ray-imaging/ada-fda-guide-patient-selection-dentalradiographs. Accessed September 29, 2020.Google Scholar However, the constraints that COVID-19 imposes upon dental practice might limit the hitherto free use of intraoral radiography, mainly due to the increased risk of producing a virus-laden aerosol. These problems prompt us to consider different technologies, such as dental panoramic radiographs (DPRs) and cone beam computed tomography (CBCT), to accomplish the goals of intraoral radiography, particularly in those cases where an aerosol is most likely to be generated by gagging or coughing (see Figure 1). The hitherto almost routine full-mouth survey (FMS) may have to become less routine. Indeed, OMR educators teach that the word routine has no place in the OMR vocabulary in accordance with the ADA selection criteria of 2012.18American Dental Association. Dental radiographic examinations: recommendations for patient selection and limiting radiation dose. https://www.fda.gov/radiationemitting-products/medical-x-ray-imaging/ada-fda-guide-patient-selection-dentalradiographs. Accessed September 29, 2020.Google Scholar The flowchart in Figure 1 guides the prescription of radiographic procedures during the recovery phase of the COVID-19 pandemic. It is organized as a broad overview covering patients who are known or suspected to have COVID-19 and those who are not. Table III compares the strengths, limitations, and radiation burdens of intraoral radiography, DPR, and CBCT.Table IIIComparison of imaging modalities available in dental officesFeatureIntraoral radiographyDental panoramic radiographyCone beam computed tomographyAvailabilityMost dental officesMost dental officesFew dental officesSpatial resolution (fine detail)HighestModerateLowestDiagnostic efficiencyBest for most studies of individual teethAdequateBest when cross-sectional information is requiredReduced complianceChildren, gaggers, and those prone to coughingBecause most require patients to stand or sit vertically, may not be ideal for elderly and ill patientsAerosol production riskHighest because of gagging and coughingLeast because nothing enters the oral cavityMovement artifactMinimal riskModerate riskHigh riskMetal artifactNoneNone, provided the patient is properly prepared and positionedGreatest, because of beam hardeningCross-sectional displayNoneNoneBestOptimal indicationsExaminations requiring fine detail: Detection of caries and periodontal bone loss, endodontic procedures in single-rooted teeth, etc.Examinations requiring wide view of maxillomandibular anatomy: Large and/or multiple lesions, impacted teeth, status of developing permanent dentition, etc.Examinations requiring 3-D images and/or extensive views of the oral and maxillofacial anatomy: Orthodontic diagnosis, implant site assessment, complex endodontic procedures, postoperative complications, large and/or multiple lesions, impacted teeth, etc.Effective radiation dose38Ludlow J.B. Davies-Ludlow L.E. White S.C. 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; 139: 1237-1243Abstract Full Text Full Text PDF PubMed Scopus (306) Google Scholar,39Ludlow J.B. Timothy R. Walker C. et al.Effective dose of dental CBCT—a meta analysis of published data and additional data for 9 CBCT units.Dentomaxillofac Radiol. 2015; 44Crossref Scopus (318) Google ScholarLeast (~2 μSv per exposure)*Assuming the use of photostimulable phosphor digital imaging or F speed film and rectangular collimation.Moderate (~14-24 μSv)†Assuming the use of a solid-state digital panoramic system.Highest (~5-1073 μSv)‡Depending on factors including field of view and exposure parameters. Assuming the use of photostimulable phosphor digital imaging or F speed film and rectangular collimation.† Assuming the use of a solid-state digital panoramic system.‡ Depending on factors including field of view and exposure parameters
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