KNOWLEDGE AND ATTITUDE TOWARD CONE BEAM COMPUTED TOMOGRAPHY: A QUESTIONNAIRE STUDY AMONG YEMENI DENTAL PRACTITIONERS

Mohammed M AlKhawlani1*, Tariq A Ziad2, Ammar A Daer3,4, Najla A Alwashali5,

Bushra M Abdulaziz6image, Abeer A Al-Sosowa7,8image

1Conservative Department, Faculty of Dentistry, Thamar University, Dhamar, Yemen. 2Private Dental Clinic, Sana’a, Yemen.

3Post doctorate Fellow at Faculty of Dentistry, McGill University, Montreal, Canada.

4Department of Orthodontic, Faculty of Dentistry, Sana'a University, Sana’a, Yemen.

5Department of Oral Pathology, Faculty of Dentistry, Thamar University, Dhamar, Yemen.

6Department of Orthodontic, Faculty of Dentistry, Thamar University, Dhamar, Yemen.

7Department of Periodontics, School of Stomatology, Lanzhou University, Lanzhou, China.

8Department of Periodontics, Faculty of Dentistry, Thamar University, Dhamar, Yemen.

ABSTRACT 

Background: Cone beam computed tomography (CBCT) is a marvelous three-dimensional (3D) dental and maxillofacial imaging method industrial in recent years. It is based on a multi-surface resampling process that has distinct advantages such as condensed radiated area size, image resolution, fast scanning time, exclusive maxillofacial imaging patterns and reduced image errors.

Objectives: This study aimed to evaluate the knowledge and attitude of a sample of Yemeni dentists toward the use of CBCT.

Methods: A total of 98 selected dentists participated in this study. The self-administered questionnaires, consisting of two parts, were distributed: The first is related to the demographic characteristics and the second section is related to the knowledge and attitude of the dental practitioners towards CBCT. The study was conducted in Dhamar city, Yemen. 

Results: The majority of respondents were 86 general dental practitioners (87.8%), most of whom were working in private dental clinics. More than half of the participants (67.3%) used digital imaging techniques to take radiographs. The most frequent source of knowledge about respondents' digital imaging techniques was the Internet (39%). Awareness of CBCT was higher in dentists, dental specialists, and those who were in an academic position. Lower radiation dose (26%), followed by secure image processing (23%), and short scanning time (21%) were the most common advantages of CBCT reported by the respondents. 

Conclusion: Study participant responses reflect the importance of CBCT in the dental field. Awareness about CBCT among dentists in Yemen is good and appears to be different among dentists with regard to gender, qualifications and type of work. The study requires that continuing learning courses be held in dental colleges in Yemen including appropriate hands-on CBCT training and integration with other clinical courses to improve the dentist’s basic knowledge and interpretation regarding this technology.

Keywords:  Attitude, CBCT, dental practitioners, knowledge, Yemen.

 

INTRODUCTION

 

Since 1896, radiography has formed an important part of the clinical assessment, diagnosis and treatment of dental patients1. Two-dimensional (2D) radiographic images have been used in dentistry for decades, basically Intraoral, panoramic and cephalometric radiographs. Due to the complex 3 dimensional (3D) anatomy of the oral and maxillofacial region, the traditional dental modalities may fail to provide optimal visualization of adjacent overlying structures, which can get superimposed in any projection, this has resulted in many efforts to obtain 3D radiography and overcome the limitations of 2D imaging2. The invention of computed tomography (CT) in 1979 is considered to be the greatest innovation in the field of radiology, providing cross-sectional images with a better insight of the structures of the body and lesions, thereby increasing the chances of recovery. However, its application in dentistry is considered limited because of its high cost, access, and radiation dose considerations3. In the late 1990s, Arai et al., and Mozzo et al., independently introduced cone beam computed tomography (CBCT) scanners for the oral and maxillofacial (OMF) region as an alternative to conventional CT2.  One benefit of CBCT technology, its ability to provide sub-millimeter (0.1mm or even less) resolution in terms of images4. The images provided are also high in diagnostic quality1,2. Moreover, CBCT has several advantages over conventional CT making it the first choice among dental professionals, including reduced cost and space requirements, a more rapid scanning time, limit the beam to the head and neck, reduction in the radiation doses, the ability to take different images from a certain structure and the possibility of reconstructing sagittal and coronal views4-7. However, CBCT gives increased radiation doses to patients compared with conventional dental radiographic techniques8. Other disadvantages of CBCT are the low resolution of its soft tissue and scattering beams from tooth tissue7.

Previous studies showed that the effective radiation dose of CBCT ranged between 0.035 and 0.10 µSv, which is equivalent to approximately a full mouth series of periapical or 3-10 standard dental panoramic tomography. The above dose is up to a 98% lower compared to conventional CT, being about 0.4 µSv1, 9. In spite of the fact that the dose and the cancer risk from dental CBCT are almost negligible for an individual patient, extensive use of radiation covering large populations should not be allowed without proper justification, with a specific focus on children. The justification step is often the most efficient step for patient dose reduction. One of the important factors in CBCT optimization is the selection of an appropriate field of view (FOV) according to clinical indication2,10.

Common indications for CBCT in dentistry are implantation, orthodontic treatments, assessment of temporo-mandibular joint, proximity of third mandibular molar with inferior alveolar nerve previous to extraction, planning orthognathic surgery and endodontic review5,7,11. Also, CBCT has been indicated in craniofacial clinical practice for diagnosing as well as pre-surgical planning of different types of acquired and congenital craniofacial malformations, like; cleft palate, facial trauma, root fractures, inflammatory bony changes and benign and malignant tumors12. In addition, CBCT imaging can assess airway shape and volume in patients with obstructive sleep apnea (OSA)13.

It has been recommended that CBCT should be performed as an auxiliary imaging technique. However, due to a lack of strict guidelines and ignorance about the role of CBCT in dentistry, it has become a substitute for conventional radiography, including periapical, bitewing, and panoramic radiographs2,6,14. Some criteria have been laid down by the American Academy of Oral and Maxillofacial Radiology for the role of CBCT in implants, endodontics, and orthodontics14. The American Dental Association Council on Scientific Affairs Council has encouraged CBCT operators to contribute in continuing education courses in order to ensure that practitioners have a satisfactory understanding of radiation safety in the dental care setting. So, CBCT imaging should only be recommended by a clinician who has undergone appropriate training in CBCT radiology and exhibits an acceptable knowledge concerning the applications of CBCT, along with experience in the interpretation of CBCT images and an appreciation of the limitations of CBCT2,15. The aim of this survey was to assess awareness, knowledge and attitude among dentists in Yemen towards CBCT use.

 

MATERIALS AND METHODS

 

A total of 120 self-administered questionnaires were distributed to dental practitioners in, Dhamar city, Yemen. The questionnaires were printed and disseminated personally by the authors. The questionnaire was adopted from some previous studies16,17. Only completely filled-in questionnaires were included in the analyses. The questionnaire consisted of two main sections. The first is related to the demographic characteristics including: gender, qualification, year of graduation, and type of work. The second section is related to the main objective of the study (CBCT) including 2 parts relating to knowledge and attitude of the dental practitioners towards CBCT. In the knowledge part dentists were asked the use or order of digital imaging, reason for not ordering digital imaging, and their awareness of CBCT in dental radiology. In the attitude part dentists were asked about attending courses related to CBCT, advising CBCT in their dental practice, and conducting continuous dental education (CDE) in CBCT. Data were presented in the terms of frequencies and percentages. The statistical package for social sciences (SPSS V25) was used for analyzing the data.

 

RESULTS

 

A total of 98 dentists (53.1% male and 46.9% female) participated in this study (response rate 82%). Among them, 86 (87.8%) were general dental practitioners and 12 (12.2%) were specialists. About half of respondents (52.0%) were working in private dental clinics, 12.2% in academic positions, 17.3% in more than one, and 9.2% in governmental or none, of an equal position (Table 1). More than half of the respondents (67.3%) used digital imaging techniques to obtain radiographs. The main reason why respondents did not request digital imaging is its high cost (59.4%) (Table 2), while the main reasons for requesting were a lower radiation dose (26%), followed by a short time (24%) (Figure 1). 

About two thirds (67.3%) of respondents were familiar with CBCT at dental radiology. The Internet was the most frequent source reported by respondents (39%), followed by lessons by faculty (26%), and seminars or workshops (25%) (Figure 2). 

Most respondents (79.6%) claimed that they have CBCT in their dental institution and about 77.6% did not attend courses related to CBCT while 63.3% were willing to attend such courses in future. Less than half of respondents (48.0%) advised CBCT for diagnosis while, 70.4% liked to use CBCT in future.

More than 60% of respondents claimed that no adequate teaching relating to CBCT was given to undergraduate students and less than 50% believed that workshops should be conducted for it (Table 3). 

The most frequently advantages of CBCT cited by respondents were lower radiation dose (26%), followed by easy image processing (23%), and short scanning time (21%) (Figure 3). 

Implant dentistry and evaluation of cyst and tumors, equally (23%), followed by evaluation of impactions (19%) were the most cases for which dentists will use CBCT in future (Figure 4). Table 4 shows the dentists’ responses to some CBCT questions distributed by gender, qualification, and type of work. Male dentists, dental specialists, and those who were in academic position were more aware of CBCT in dental radiology and used/ordered more digital imaging modalities. While, male dentists, dental specialists, and those who had more than one work position attended more courses related to CBCT.

Responses to the question related to the teaching given to undergraduate students, almost all dentists respond negatively that the teaching of CBCT was not enough. Regarding dentists’ opinions about the future use of CBCT in dental practice, the majority of responses were toward the use of CBCT in all specialties of dentistry (Table 5). Male dentists, dental specialists, and dentists in academic, governmental and combined 

positions agreed that CBCT workshops should be conducted while, majority of responses by gender, qualification, and type of work were toward the use of CBCT in future. However, in response to the question related to the advice of CBCT for diagnosis, female dentists, general dental practitioners, and dentists in private, academic, and governmental positions did not advise CBCT for diagnosis in their dental practice (Table 6).

 

DISCUSSION

 

Studies assessing awareness, knowledge and attitude of CBCT among dentists and specialists are rare. This study used a questionnaire to assess the level of knowledge regarding CBCT among a sample of Yemeni dentists and specialists. Correct diagnosis and treatment planning of patients seeking various dental procedures sometimes need several radiographic imaging techniques16,17. Among those radiographic techniques, CBCT has been shown to have a wide application in dentistry18,19. This study showed that more than half of respondents (67.3%) were aware of CBCT. In contrast, a higher percentage was published by Rai et al.20, in their study among Indian dentists and a lower percentage were obtained by Aditya et al.21, who reported that low awareness regarding applicat-ions of CBCT among practitioners causes widely less use of CBCT in clinical practice20,21. They reported that the majority of their participants did not advice CBCT at all or advice in less than one-fourth of their cases. This could be due to low availability of the technique, high cost or inability of case selection for CBCT imaging by the dentists21. The current study revealed that, the main reasons for ordering CBCT were less radiation dose (26%) followed by short time (24%). This was in agreement with the findings published by Rai et al.20, and also Chau and Fung22 who mentioned that CBCT causes the lowest radiation dose to the organs. A higher value was recorded by Balabaskaran and Srinivasan in which 80.48% of participants revealed that the most advantage of CBCT over CT was the lower radiation. About 87.8% revealed that CBCT offers enhanced diagnosis at a lower dose than CT23.Male dentists, dental specialists, and those who were in academic position were more aware of CBCT in dental radiology and used/ordered more digital imaging modalities. About two thirds (67.3%) of the respondents were aware of CBCT in dental radiology. To a great extent, similar findings were seen in Turkey, Middle East, and India by Kamburoglu et al.24, Zain Alabdeen, and El Khateeb25 and Rai et al.20, respecti-vely. Other studies showed less awareness amongst the dentists regarding applications of CBCT in India which could be due to lack of availability of CBCT centers and non-inclusion of CBCT training during dental education21,26,27. In Turkey, Kamburoglu et al., noted in their study among Turkish dental students that there was a very low awareness about CBCT24. The Internet was the most frequent source reported by respondents (39%), followed by lessons by faculty (26%), and seminars or workshops (25%). Male dentists, dental specialists, and those who had more than one work position attended more courses related to CBCT. Higher percentages were reported by Rai et al.20, (72.2%) and Balabaskaran and Srinivasan23 (48%) among the dentists who obtained knowledge about CBCT through lectures. Kamburoglu K et al.24, claimed that, 63.3% of students had heard of CBCT, 59.9% of them had learned about CBCT in their classes, 31.0% in seminars and 20.9% from the internet. In contrast, Zain-Alabdeen and El-Khateeb25 reported that the source of CBCT knowledge was postgraduate training in Saudi Arabia and Egypt, whereas in Jordan, it was seminars and workshops. In Turkey, the main source of CBCT knowledge for dental students was seminars; however, the rating for CBCT courses was poor in the study24.In this study, more than 60% of respondents claimed that no adequate teaching relating to CBCT was given to undergraduate students and less than 50% believed that workshops should be conducted with this regard. Responses to the question related to the teaching given to undergraduate students, almost all dentists respond negatively that the teaching of CBCT was not enough for undergraduate students. This is in line with the findings obtained by Rai20, and Aditya et al., among Indian dentists. In contrast, Kamburoglu et al.24, in their study revealed slight higher percentage in which 76.8% felt that CBCT was not covered enough in their courses and 69% thought that CBCT should be taught as part of their clinical education; 91% thought that CBCT should be available at dental faculties. Zain-Alabdeen and El-Khateeb25 suggested the development of Curriculum and incorporate CBCT training in undergraduate studies.

In our study, less than half of respondents (48.0%) advised CBCT for diagnosis while, 70.4% liked to use CBCT in future. Female dentists were less likely to advice CBCT than male dentists. This might be attributed to the fact that the number of female specialists is lower than male ones. Moreover, females are less likely to perform complicated cases which require more investigations28. Implant dentistry and evaluation of cyst and tumors, equally (23%), followed by evaluation of impactions (19%) were the most cases for which dentists will use CBCT in future. These findings were in accordance with Rai et al.20, Balabaskaran and Srinivasan23. Zain-Alabdeen and El-Khateeb25 reported that implant was the indication with the highest frequency, followed by impaction and jaw pathology at equal frequency and then TMJ and endodontic. A study done by Strindberg et al.29, in Sweden showed that implant was the indication with the highest frequency and impaction was the second highest indication, followed by jaw pathology, and a pain related condition. Most of the relevant studies reported that CBCT is used mostly for implants20-25,29. Regarding dentists’ opinions about the future use of CBCT in dental practice, the majority of responses were toward the use of CBCT in all specialties of dentistry which was in harmony with most of other studies. Many studies showed that dentists wanted to use CBCT technology in the near future in their clinical practice20,23,24.

 

CONCLUSION

 

Study participant responses reflect the importance of CBCT in the dental field. Awareness about CBCT among dentists in Yemen is good and appears to be different among dentists with regard to gender, qualifications and type of work. The study requires that continuing learning courses be held in dental colleges in Yemen including appropriate hands-on CBCT training and integration with other clinical courses to improve the dentist’s basic knowledge and interpretation regarding this technology.

 

CONFLICT OF INTEREST

 

The authors declare that they have no conflict of interest.

 

AUTHOR’S CONTRIBUTION

 

Mohammed M. AlKhawlani participated in the conceptual framework, designing, and writing of the manuscript. Tariq A. Ziad and Ammar A. Daer participated in data analysis, and writing the manuscript. Ammar A. Daer, Najla A. Alwashali, Bushra M. Abdulaziz, and Abeer A Al-Sosowa participated in writing the manuscript. All authors read and approved the final manuscript.

 

ACKNOLEDGEMENT

 

The authors would like to acknowledge all dentists who participated in this study.

 

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