Dentomaxillofacial Radiology (2014) 43, 20130291

ª 2014 The Authors. Published by the British Institute of Radiology

http://dmfr.birjournals.org

SHORT COMMUNICATION
Basic training requirements for the use of dental CBCT by
dentists: a position paper prepared by the European Academy of
DentoMaxilloFacial Radiology
J Brown1, R Jacobs2, E Levring Jäghagen3, C Lindh4, G Baksi5, D Schulze6 and R Schulze7
1
King’s College London—Dental Institute, Dental Radiology, Guy’s Hospital, London, UK; 2OMFS IMPATH Research Group,
Department of Imaging and Pathology, Faculty of Medicine, University of Leuven, Leuven, Belgium; 3Oral and Maxillofacial
Radiology, Department of Odontology, Umeå University, Umeå, Sweden; 4Department of Oral and Maxillofacial Radiology,
Faculty of Odontology, Malmö University, Malmö, Sweden; 5Department of Oral and Maxillofacial Radiology, Ege University,
School of Dentistry, Bornova, Izmir, Turkey; 6Dental Diagnostic Center, Freiburg, Germany; 7Department of Oral Surgery
(and Oral Radiology), University Medical Center of the Johannes Gutenberg—University Mainz, Mainz, Germany

Cone beam CT (CBCT) is a relatively new imaging modality, which is now widely available
to dentists for examining hard tissues in the dental and maxillofacial regions. CBCT gives
a three-dimensional depiction of anatomy and pathology, which is similar to medical CT and
uses doses generally higher than those used in conventional dental imaging. The European
Academy of DentoMaxilloFacial Radiology recognizes that dentists receive training in two-
dimensional dental imaging as undergraduates, but most of them have received little or no
training in the application and interpretation of cross-sectional three-dimensional imaging.
This document identifies the roles of dentists involved in the use of CBCT, examines the
training requirements for the justification, acquisition and interpretation of CBCT imaging
and makes recommendations for further training of dentists in Europe who intend to
be involved in any aspect of CBCT imaging. Two levels of training are recognized. Level 1
is intended to train dentists who prescribe CBCT imaging, such that they may request
appropriately and understand the resultant reported images. Level 2 is intended to train to
a more advanced level and covers the understanding and skills needed to justify, carry out and
interpret a CBCT examination. These recommendations are not intended to create specialists
in CBCT imaging but to offer guidance on the training of all dentists to enable the safe use of
CBCT in the dentoalveolar region.
Dentomaxillofacial Radiology (2014) 43, 20130291. doi: 10.1259/dmfr.20130291

Cite this article as: Brown J, Jacobs R, Levring Jäghagen E, Lindh C, Baksi G, Schulze D, et al.
Basic training requirements for the use of dental CBCT by dentists: a position paper prepared
by the European Academy of DentoMaxilloFacial Radiology. Dentomaxillofac Radiol 2014;
43: 20130291.

Keywords: cone beam computed tomography; education; training; guidelines

There has been a rapid uptake of cone beam CT (CBCT) there is a need to specify the training requirements for
imaging in oral healthcare in Europe. The European dentists using CBCT equipment to ensure the protection of
Academy of DentoMaxilloFacial Radiology (EADMFR), patients undergoing this examination, as higher radiation
in keeping with its mission to serve as a resource for im- doses are used than in conventional dental X-ray exami-
aging in the dentomaxillofacial area, recognizes that nations. The working party of the EADMFR has
reviewed the current literature, national guidelines and
information available to professional organizations to
Correspondence to: Dr Jacqueline Brown, King’s College London—Dental
Institute, Dental Radiology, Floor 23, Guy’s Tower, Guy’s Hospital, St Thomas
prepare this position paper. The training recommended
Street, London, UK. E-mail: jackie.brown@kcl.ac.uk in this document is not intended as appropriate or ade-
Received 8 August 2013; revised 9 October 2013; accepted 10 October 2013 quate training to create “specialists” in dental and

1
 Training for the use of dental CBCT: EADMFR position paper
2 of 7 J Brown et al

maxillofacial radiology (DMFR), nor is it intended to level of continuing education required, depending on
cover training for operators, technicians or radiogra- how a dentist uses CBCT.
phers. It is applicable to all dentists who are not spe- DMFR is a registered speciality with formal training
cialized in radiology and takes into account the varying curricula in only a few countries in Europe, including
roles a dentist may play in the use of CBCT. Through- Norway, Sweden, UK, Finland and Turkey. Many
out this document, the term “dentist” is used to en- other countries, however, have more informal special-
compass dental practitioners engaged in general dental ists, including researchers in the area or physicians
care and/or specialist practice other than DMFR. specialized in DMFR. In these European countries,
a DMFR specialist or a medical radiologist may be
required to perform or take responsibility for CBCT
Introduction examinations, because these examinations are governed
by the same restrictions and regulations as multislice
Cone beam CT (CBCT) has been available to dentists medical CT scanning.7 However, in most countries
since the late 1990s and has experienced a massive surge throughout Europe, CBCT is generally available to all
in popularity over recent years. As new equipment has dentists. In keeping with the general trend in many
been developed with ever more advanced imaging European countries towards an increasing usage of
capabilities, CBCT has come to represent the accepted medical 3D imaging techniques such as CT,8,9 it seems
standard for three-dimensional (3D) hard tissue imaging very likely that this will be mirrored in dental imaging.
in DMFR. It is well recognized that medical imaging has come to
The use of ionizing radiation in medical imaging has represent the largest man-made source of ionizing ra-
always had implications in radiation protection for diation in developed countries over recent years.8 The
medical staff, public and patients. It has always been rapid increase in the numbers of relatively high-dose CT
advocated that the “as low as reasonably achievable” examinations that are performed has resulted in signif-
principle should be followed,1 and that doses should be icant consequences for individual patient doses and the
kept as low as reasonably practicable, economic and collective dose to the entire population.8 Risk assess-
social factors having been considered.2 The EADMFR ments based on this increased population dose, partic-
also proposes that as a general rule, the field of view ularly for paediatric patients, concluded that the cancer
(volume) should be limited to the area of interest, and risk associated with CT is not hypothetical.10 Although
the report should always cover the full volume. the effective doses delivered by CBCT in general are
The increasing availability and use of CBCT now considerably lower than those for CT,5 its anticipated
inevitably requires the dentist to evaluate these novel uptake will undoubtedly result in an increase in the
images for their patients. Across Europe, however, there collective dose to the population. Greater emphasis
are differences in depth, extent and structure within the needs to be placed on radiation protection for both
DMFR curriculum for undergraduate dentistry, and patients and staff in dental practice, and more stringent
training comes under differing national governmental regulations already exist to govern the use of CBCT in
restrictions concerning the right to use radiation. Un- many European countries. The increased dose of ion-
dergraduate curricula have also changed over time, as the izing radiation brings greater responsibility for justifi-
importance of acquiring knowledge in DMFR has in- cation of CBCT scans, such that a favourable ratio of
creasingly been recognized. These are important aspects benefit to risk can be achieved. Yet, even if the justifi-
to consider when developing curricula and preparing cation process is stringent, an inadequate evaluation of
courses to include continuing education in CBCT, since the resultant 3D images by dentists, owing to lack of
prior knowledge will differ between dentists depending training, remains a concern. Even if undergraduate
on the country and date of qualification. In reality, the training in CBCT and its interpretation improves over
majority of current dental practitioners will have received time, this does not address the deficiencies of dentists in
insufficient or no training in interpreting CBCT images, the interim period, which will persist for several years.
and they will not have been trained to justify or perform In the longer term, implementation of well-designed
scans. This deficiency in dental education, while acknowl- university-based post-graduate training, together with
edging differing baseline training and experience, should be up-to-date basic CBCT training in undergraduate den-
addressed. tal education, should result in more widespread acqui-
Previous reviews of dentists’ attitudes towards the sition of appropriate skills, both in CBCT justification
use of ionizing radiation and the selection criteria in and image interpretation. As part of post-graduate ed-
dental radiology have shown a need for extension of ucation, certification of CBCT users should be consid-
continuing education courses in conventional two- ered by national bodies responsible for radiation use and
dimensional imaging.2–4 Considering that higher radi- safety, who may find guidance in the contents of this
ation doses are used when CBCT examinations are per- document.
formed,5,6 it is even more important that anyone using These concerns about training a dentist in CBCT led
this technique understands the justification of patient to the preparation of this position paper, which aims to
exposure, optimization of patient dose and protection provide a framework of the basic requirements that
for staff from radiation. Differences will exist in the should be met by a general dentist if he/she (i) prescribes,

Dentomaxillofac Radiol, 43, 20130291

 Training for the use of dental CBCT: EADMFR position paper
J Brown et al 3 of 7

(ii) justifies or (iii) carries out CBCT examinations, or The aim of this document is to recommend a minimum
(iv) interprets CBCT images. level and core content (Table 1) of training for dentists in-
volved in CBCT imaging in dental practice within Europe.
Background
Roles and responsibilities
In January 2009, EADMFR published its Basic principles
for the use of dental cone beam computed tomography,11 Dentists involved in CBCT may fall into one or more of
which stated, under Point 18: the following categories, which are recognized as
“Dentists responsible for CBCT facilities who have not “entitlement roles” by the European Directive. Each
previously received ‘adequate theoretical and practical role carries specific responsibilities defined by the regu-
training’ should undergo a period of additional theoret- lations. In addition, EADMFR’s basic principles11 re-
ical and practical training that has been validated by an quire that all those involved with CBCT as shown below
academic institution (University or equivalent). Where must have received adequate theoretical and practical
national specialist qualifications in DMFR exist, the design training for the purpose of radiological practices and
and delivery of CBCT training programmes should involve relevant competence in radiation protection.
a DMF Radiologist.”
This statement was reinforced by the SEDENTEXCT The Prescriber
working group and has now been ratified and published A medical doctor, dentist or other health professional who
by the European Commission.5 Training in the use of is entitled to refer individuals for medical exposure to
new imaging equipment and techniques is an important a practitioner following further training and in accordance
part of effective radiation protection. EADMFR wishes with national requirements. The Prescriber is involved in
to promote optimal CBCT imaging in dentistry within the justification process at the appropriate level and would
a safe radiation protection environment. The Academy need to supply adequate levels of clinical information.
has consulted members from across the European Union
and examined the existing guidelines on CBCT usage The Practitioner
and training, which are currently available in countries
around Europe, and has developed the following position A medical doctor, dentist or other health professional
statements on training for CBCT in dentistry. EADMFR who is entitled to take clinical responsibility for an in-
supports the International Commission on Radiation dividual medical exposure following further training and
Protection principles of radiation protection and would in accordance with national requirements. The Prac-
like to promote these in relation to CBCT imaging. The titioner undertakes the justification of radiographical
International Commission on Radiation Protection’s key exposure, weighing benefit against risk and considering
concepts of justification, optimization and dose limita- safer alternatives.
tion for radiation protection are each relevant and should
be applied to CBCT. The medical physics expert
Appropriate training is the basis for effective imple- An expert in radiation physics or radiation technology
mentation of these principles. The European Directive12 applied to exposure, within the scope of the Directive,
requires that member states of the European Union ensure whose training and competence to act is recognized by
that any individual involved in radiological imaging has the competent authorities and who, as appropriate, acts
adequate and appropriate theoretical and practical training or gives advice on patient dosimetry, on the development
to undertake and, where appropriate, interpret a radiologi- and use of complex techniques and equipment, on op-
cal examination, as well as relevant competence in radia- timization, on quality assurance, including quality con-
tion protection. EADMFR supports the concept that all trol, and on other matters relating to radiation protection,
those involved in all aspects of CBCT imaging should be concerning exposure within the scope of the Directive.12
adequately trained for the role that they play. It is rec- This EADMFR working group also recognizes that a
ognized that roles may vary and that training needs to be further role will exist in some countries, as defined below.
tailored to the varying roles within the dental team.
EADMFR understands that there is variation among
The Prescriber who reports
member countries in the availability of specialists in
DMFR or radiologists with special knowledge in A medical doctor, dentist or other health professional
DMFR and that there are national variations in the who is entitled to refer individuals for medical exposure
clinical practice of dentistry and in current national to a practitioner, in accordance with national requirements,
requirements for further training in new CBCT equip- and who reports on the resultant CBCT examination.
ment. EADMFR endorses the core curriculum for These prescribers are involved in the justification
training in CBCT recommended by SEDENTEXCT5 process at the appropriate level, the need to supply
as an appropriate outline for training, which recog- adequate levels of clinical information to the practi-
nizes differing levels of training requirements depending tioner and the evaluation/interpretation of the delivered
on the role of the individual. examination.

Dentomaxillofac Radiol, 43, 20130291

 Training for the use of dental CBCT: EADMFR position paper
4 of 7 J Brown et al

The above roles provide a framework which is com- that the course (at least at Level 2) is carried out in a venue
monly used in European countries and may be used when where sessions of hands-on training can be provided.
developing new guidelines concerning CBCT. Each Because techniques and knowledge develop over
country, however, also has domestic regulations, which time, it is recommended that refresher courses are
the following recommendations do not over-rule. These attended regularly.
roles above may be interpreted for application in CBCT
imaging as follows. A dentist will act either as a Prescriber,
when he/she refers a patient to another dental practice or Learning outcomes
hospital for CBCT imaging, or as a Practitioner, when he/
she offers a CBCT imaging service to other dentists, or as
The following learning outcomes have partly been de-
both Prescriber and Practitioner if he/she prescribes and
veloped by the SEDENTEXCT working group.
performs CBCT imaging. As a Prescriber, the dentist may
The following learning outcomes should be achieved,
refer a patient for a CBCT scan, but he/she does not take
and on completion of the course, the learner should have
ultimate responsibility for the radiological exposure,
demonstrated:
which is the task of the Practitioner. The Prescriber’s re-
sponsibility is to supply sufficient clinical information so Knowledge and understanding
that the Practitioner may justify the examination, and the
Practitioner must also decide on optimum exposure pro-
tocols for the task. In some countries, legislation may Level 1:
allow the Practitioner to delegate parts of this role to • knowledge of the concept of the imaging “chain”
suitable trained staff under written protocols. A clinical
from initiating the X-ray exposure to display of the
evaluation of the image (radiological report) is essential
image
and is mandatory in some European countries. Either the • knowledge of how X-rays interact with matter
Prescriber or the Practitioner may report on the resultant • knowledge of biological effects of radiation
CBCT examination, depending on national legislation and • knowledge of background radiation and its origin
guidelines, and it is required that they become adequately • knowledge of the principles of image detectors and
trained in 3D diagnostic interpretation of the dentoal-
their influence on image quality
veolar region and facial skeleton. They should also be • knowledge of the selection criteria for intraoral and
aware of anatomy and disease in adjacent structures to
panoramic radiography and its influence on radiation
be able to judge when to refer the patient for exami- protection
nation to specialists in DMFR or medical radiology. • understanding of the difference between two-
The EADMFR working party recommend that the
dimensional and 3D imaging
radiological report is best prepared by the Practitioner, • knowledge of the regulations that direct the use of
in light of their knowledge of the justification and im-
CBCT in their own country and an overview of dif-
aging parameters during examination.
ferences in Europe
• understanding of the importance of gaining new
Levels of education knowledge by following scientific developments
and improvements in diagnostic imaging and
technology.
At least two levels of continuous education are necessary
for general dentists:
Level 2:
Level 1
• knowledge of the factors controlling X-ray quantity,
A basic level, directed at Prescribers with limited knowl-
quality and geometry and its influence on image quality
edge of CBCT as an imaging modality and radiology • knowledge of the construction and function of CBCT
in general (i.e. education in selection criteria, technology,
equipment
radiation protection, outcome, interpretation of the exami- • understanding of the principles of CBCT radio-
nations and influence on patient treatment).
graphical techniques
• understanding of the principles of reformatting image
Level 2
data
An advanced level directed at Practitioners and all those • knowledge of selection criteria for examination with
who report on CBCT imaging. It would include hands- CBCT
on use of software for optimizing the examinations and • knowledge of principles of diagnostics and how
in-depth knowledge of justification and interpretation of diagnostic radiology relates to other diagnostic
CBCT examinations, and when consultancy and further methods
referral is necessary. • knowledge of selection criteria for examination with
To attend Level 2, the learning outcomes formulated CBCT
for Level 1 must be fulfilled. It should be mandatory • knowledge of preparation of a structured report.

Dentomaxillofac Radiol, 43, 20130291

 Training for the use of dental CBCT: EADMFR position paper
J Brown et al 5 of 7

Table 1 General training content

Role
Instruction type The Prescriber The Practitioner
A dentist who refers for a CBCT examination and A dentist responsible for performing the CBCT
reviews the images, including the report from the examination (also including the Prescriber who
Practitioner, for clinical use reports the CBCT examination). This person will
normally report on the images but may delegate this
role to another individual
Training content
Theoretical instruction Justification and referral criteria for dental CBCT5,13 Justification and referral criteria for dental CBCT5,13
Radiation physics in relation to CBCT equipment Radiation physics in relation to CBCT equipment
Radiation doses and risks involved with CBCT Radiation doses and risks with CBCT
Radiation protection in relation to CBCT equipment, Radiation protection in relation to CBCT equipment,
including justification (referral/selection criteria) and including justification (referral/selection criteria) and
relevant aspects of optimization of exposures relevant aspects of optimization of exposures
CBCT equipment and apparatus CBCT equipment and apparatus, technical
background information
CBCT image acquisition, digital imaging and
communications in medicine standard and processing
Practical instruction Principles of CBCT imaging
Use of different CBCT equipment
CBCT imaging techniques and measures for dose
reduction
Use of software to optimize patient dose and image
interpretation
Quality assurance for CBCT
Care of patients undergoing CBCT
Radiological interpretation Principles and practice of interpretation of Principles and practice of interpretation of
dentoalveolar CBCT images of the teeth, their dentoalveolar CBCT images of the teeth, their
supporting structures, the mandible and the maxilla supporting structures, the mandible and the maxilla
up to the floor of the nose (e.g. smaller fields of view) up to the floor of the nose (e.g. smaller fields of view)
and of the facial skeleton (e.g. larger fields of view) and of the facial skeleton (e.g. larger fields of view)
Normal radiological anatomy on CBCT images Normal radiological anatomy on CBCT images
Artefacts on CBCT images Artefacts on CBCT images
Radiological interpretation of disease affecting the Radiological interpretation of disease affecting the
teeth and jaws and facial skeleton on CBCT images teeth and jaws and facial skeleton on CBCT images
Interpretation of a received report Interpretation of anatomy and disease in adjacent
structures to the teeth and their supporting
structures and of the facial skeleton.
Writing a structured radiological report14,15
CBCT, cone beam CT.
Reproduced with permission from the British Institute of Radiology. Adapted from5 and originally published in11.

Skills and ability • ability to differentiate between findings indicative of

normal anatomical structures from those of diseased
Level 1: teeth, jaws and the facial skeleton
• ability to analyse disease and create a report of CBCT
• ability to use CBCT equipment images
• ability to describe and implement the regulations that • ability to identify and critically review adequate
direct the use of CBCT scientific literature.
• ability to support staff development in the use of CBCT
• ability to analyse normal anatomical structures of
the teeth, jaws and facial skeleton in CBCT images Judgment and stance
• ability to recognize anatomy and disease of the teeth Level 1:
and their supporting structures in CBCT images
• ability to search/identify adequate scientific literature. • judgment to strive for a minimized radiation dosage
to patients and staff
• responsibility for own competence development in the
Level 2:
field of DMFR.
• ability to recognize malfunctioning of CBCT devices Level 2:
• ability to perform a quality control programme for
CBCT devices • responsibility for staff development in the field of DMFR
• skills in practical use of software and other measures • judgment to identify when to refer for a second opinion
for radiation protection or over-read.

Dentomaxillofac Radiol, 43, 20130291

 Training for the use of dental CBCT: EADMFR position paper
6 of 7 J Brown et al

Practical aspects of course delivery and radiologists, where a general dentist, or any dental
time requirements specialist outside the field of radiology, refers for CBCT
scans or operates CBCT machines.
There is a great deal of variation among member nations EADMFR, as the official organization for DMFR in
on the time required for training in CBCT. Almost all Europe, recognizes the additional educational demands
members agree that the dentist should build on prior that these techniques pose for the users. This position
training in radiation protection, radiographical techniques paper is a direct reaction to these demands, which have
and interpretation gained during undergraduate training. become evident over the past few years. It aims to provide
Most countries also recognize the requirement to train in basic guidance on training in topics and issues that should be
both the theoretical and the practical aspects of CBCT familiar to a dentist referring for, or justifying, CBCT
examinations. examinations, when operating a machine and when inter-
Given the content of the learning outcomes and the preting CBCT images. The discrimination between the
recommended adequate training (Table 1) specified different roles that a dentist may have in the process, as
above, the working party recommends that: suggested by the SEDENTEXCT group,5 i.e. “Prescriber”
and “Practitioner”, allows the definition of different
• For Level 1, this cannot be delivered in less than 12 h requirements tailored to the specific needs of each group.
of theoretical and practical training. Essential sources for this article were the work of the
• To attend Level 2, the learner should have passed SEDENTEXCT group and the Basic principles for use
a Level 1 course successfully. of dental cone beam computed tomography: consensus
• For Level 2, this cannot be delivered in less than 12 h guidelines of the European Academy of Dental and
of theoretical training and an additional 12 h of Maxillofacial Radiology published in 2009.11 Based on
training in practical aspects of CBCT. these sources, an expert group within EADMFR de-
• For Levels 1 and 2, interpretation would be included veloped the requirements and learning outcomes de-
at an appropriate level (the theory and principles of tailed in this article over a 1-year period. The position
interpretation, report preparation and practical exer- paper was also internally reviewed by additional experts
cises in interpretation). For Level 2, it is recommended from the SEDENTEXCT group. Thus, the position paper
that, additionally, further case reports are undertaken represents expert opinion from international specialists in
as case discussions. DMFR who have already been involved in CBCT training
• The learning outcomes should be adequately assessed for several years and who have acquired experience in un-
to ensure that these have been achieved. For Level 2, dergraduate and post-graduate CBCT training. The guid-
this should include presentation of case reports. ance presented here should be viewed as suggestions for
minimum training requirements and demands as derived
Discussion and conclusion from current knowledge. Of course, these suggestions are
not legally binding, nor can they replace national regu-
While CBCT faces increasing application in DMFR, lations. Rather, this position paper aims to provide a com-
the level of knowledge among dentists, who often mon source of recommendations for all those interested and
operate these sophisticated machines, may not always be involved in CBCT imaging. EADMFR recognizes that the
sufficient to meet the considerable demands imposed on educational situation, and status of CBCT knowledge, will
performing justification, acquisition and, particularly, change with time. The same applies for experience gained
interpretation of CBCT images. This discrepancy is from implementation and application of the information
mainly owing to the relative novelty of the technique presented here.
and the lack of education received during a dentist’s un- In conclusion, this position paper on the basic require-
dergraduate studies. Because the dose of ionizing radia- ments for the use of CBCT by dentists not specialized in
tion delivered by CBCT is generally much higher than DMFR provides guidance on what knowledge, un-
that involved with conventional two-dimensional derstanding and training should be expected when a dentist
dental radiographic imaging, correct justification, ac- (i) prescribes, (ii) justifies and (iii) carries out CBCT
quisition and interpretation are fundamental to every examinations, or (iv) interprets CBCT images. As a po-
CBCT scan. It is important to note, however, that sition paper, it represents expert opinion developed by
specialists in DMFR, who exist in some European a dedicated panel within EADMFR established for this
countries, are not explicitly addressed in this article. It is purpose. Future developments, an increasing experience
recognized that these specialists have undergone sub- with the technique and any future changes to European
stantial further training, which includes CBCT imaging. regulations require that review and updating of this po-
Unfortunately, few European countries have established sition paper is undertaken in 5 years’ time.
such dental speciality post-graduate programmes or
have recognized the speciality at all. Thus, although
Acknowledgments
EADMFR’s suggestions are addressed to all dentists
involved in any way in CBCT examinations, the main The EADMFR working group gratefully acknowledges re-
focus of the article is to address the vast majority of view and constructive suggestions from Keith Horner and
European countries without specialist dentomaxillofacial Eric Whaites.

Dentomaxillofac Radiol, 43, 20130291

 Training for the use of dental CBCT: EADMFR position paper
J Brown et al 7 of 7

References

1. International Commission on Radiation Protection. The 2007 9. Bundesamt für Strahlenschutz. Jahresbericht 2009. Salzgitter,
Recommendations of the International Commission on Radiation Germany: Bundesamt für Strahlenschutz; 2009. Available from:
Protection. ICRP publication 103. Ann ICRP 2007; 37: 2–4. doi: http://doris.bfs.de/jspui/bitstream/urn:nbn:de:0221-201005041866/
10.1016/j.icrp.2007.10.003 3/BfS_2010_Jahresbericht_2009.pdf
2. Rushton VE, Horner K, Worthington HV. Factors influencing 10. Brenner D, Hall E. Computed tomography—an increasing source
the frequency of bitewing radiography in general dental practice. of radiation exposure. N Engl J Med 2007; 357: 2277–2284. doi:
Community Dent Oral Epidemiol 1996; 24: 272–276. 10.1056/NEJMra072149
3. Svenson B, Söderfeldt B, Gröndahl HG. Attitudes of Swedish 11. Horner K, Islam M, Flygare L, Tsiklakis K, Whaites E. Basic
dentists to the choice of dental X-ray film and collimator for oral principles for use of dental cone beam computed tomography:
radiology. Dentomaxillofac Radiol 1996; 25: 157–161. consensus guidelines of the European Academy of Dental and
4. Jacobs R, Vanderstappen M, Bogaerts R, Gijbels F. Attitude of the Maxillofacial Radiology. Dentomaxillofac Radiol 2009; 38: 187–195.
Belgian dentist population towards radiation protection. Dento- doi: 10.1259/dmfr/74941012
maxillofac Radiol 2004; 33: 334–339. doi: 10.1259/dmfr/22185511 12. European Council. Council Directive 97/43/EURATOM of
5. European Commission. Radiation protection no. 172: cone beam 30 June 1997 on health protection of individuals against the
CT for dental and maxillofacial radiology. Evidence based guidelines. dangers of ionizing radiation in relation to medical exposure, and
A report prepared by the SEDENTEXCT project. Luxembourg: repealing directive 84/466/EURATOM. Luxembourg: EC; 1997
EC; 2011 [cited Oct 2013]. Available from: ec.europa.eu/energy/ [cited Nov 2013]. Available from: http://ec.europa.eu/energy/nuclear/
nuclear/radiation_protection/doc/publication/172.pdf radioprotection/doc/legislation/9743_en.pdf
6. Pauwels R, Beinsberger J, Collaert B, Theodorakou C, Rogers J, 13. Harris D, Horner K, Gröndahl K, Jacobs R, Helmrot E, Benic
Walker A, et al. SEDENTEXCT project consortium. Effective GI, et al. EAO guidelines for the use of diagnostic imaging in
dose range for dental cone beam computed tomography scanners. implant dentistry 2011. A consensus workshop organized by the
Eur J Radiol 2012; 81: 267–271. doi: 10.1016/j.ejrad.2010.11.028 European Association for Osseointegration at the Medical Uni-
7. Stralsakerhetsmyndigheten. The Swedish Radiation Safety Author- versity of Warsaw. Clin Oral Implants Res 2012; 23: 1243–1253.
ity’s regulations on general obligations in medical and dental practices doi: 10.1111/j.1600-0501.2012.02441.x
using ionising radiation. Stockholm, Sweden: SSMFS; 2008 [cited 14. European Society of Radiology (ESR). Good practice for radiologi-
Nov 2013]. Available from: http://www.stralsakerhetsmyndigh- cal reporting. Guidelines from the European Society of Radiology
eten.se/Global/Publikationer/Forfattning/Engelska/SSMFS- (ESR). Insights Imaging 2011; 2: 93–96. doi: 10.1007/s13244-011-
2008-35E.pdf 0066-7
8. European Commission. Radiation protection no. 154: European 15. American College of Radiology. ACR practice guideline for
guidance on estimating population doses from medical X-ray communication of diagnostic imaging findings. Commun Diagn
procedures. Annex 1–DD report 1. 2008. Radiol 2010: 1–6.

Dentomaxillofac Radiol, 43, 20130291