Radiographic Prescription Trends among Palestinian Dentists for Dental Implant Placement – A Cross Sectional Survey

Background: In this present era implant dentistry has seen exponential growth and its success mainly depends upon a proper treatment planning and its execution. Radiographic imaging has a pivotal role in the planning of implant placement and follow up of implant survival. The Context and Purpose of the Study: To study the radiographic prescription trends for dental implants among Palestinian dental practitioners. A sample of 150 dentists chosen at random in a dental conference received a questionnaire. Results: 114 dentists returned full questionnaires. It was observed that the majority of the surveyed dentists prescribe panoramic radiographs for dental implant assessment based on its availability. The motivating factors for prescribing the specifi c radiologic examination was Availability (42.99%), availability + cost(17.53%), Cost + Measurement precision(3.51%), Cost + Radiation Dose(10.53%), Measurement precision(25.44%). Conclusions: The majority of surveyed dentists prescribe panoramic radiographs for dental implant assessment based on its availability and only a small number strictly adhered to the recommended guidelines of the international associations with regards to cross sectional imaging. Research Article Radiographic Prescription Trends among Palestinian Dentists for Dental Implant Placement – A Cross Sectional Survey Hakam Rabi1, Emad Qirresh2 and Tarek Rabi1* 1M.Sc. Lecturer, Al-Quds University, Palestine, Jerusalem 2Assistant Professor, Al Quds University Palestine, Jerusalem Dates: Received: 14 November, 2016; Accepted: 27 February, 2017; Published: 01 March, 2017 *Corresponding author: Tarek Rabi, M.Sc., Lecturer, Al-Quds University, Palestine, Jerusalem, E-mail: https://www.peertechz.com


Introduction
Dental Implants are being widely used for the replacement of missing teeth. Dental practitioners have remarkably taken up this treatment modality and adapted to the advancements in oral rehabilitation. The main criterion in assessing the success of oral implants has been the marginal bone loss evidenced by the radiological examination [1][2][3]. The imaging objectives aids the clinician in providing the cross-sectional views of the dental arch for visualization of spatial relationship of anatomic structures of the maxilla and mandible, the quality and quantity of available bone, the presence of infra-bony lesions, the occlusal pattern and the number and size of implants as well as prosthesis design, all which are essential for successful implant treatment planning and evaluation of the ongoing implant functioning [4]. Many  by professional bodies like AAOMR, EADMFR, EAO and ICOI [9].
Hence looking at the need of the hour, an attempt was made to survey the radiographic prescription trends among the dental practitioners.

Results
The survey was carried out on 114 dentists having clinical experience of more than 10 years (16.67 %), 6-10 years (79.82 %) and 1-5 years (3.51 %). The Gender distribution of radiographic examinations more often prescribed for dental implant assessment were shown in Figure 1. Approximately 59% of dentists prescribe panoramic x-ray whereas 41% of the dentists prescribe a combination of Panoramic X ray + CT imaging.
The motivating factors for prescribing the specifi c radiologic examination was Availability (42.99%), Availability + Cost (17.53%), Cost + Measurement precision (3.51%) Cost + Radiation Dose (10.53%), Measurement precision (25.44%), Figure 2. Tables 1,2, depict the percent population having problems in measuring panoramic X ray (OPG) and its frequency respectively. It was observed that 34 % of the dentists recommend CBCT Figure 3, with overall medium frequency of 76%, low 3% and minimal 0%. The usage of periapical radiography and the reason for its usage has been shown in Figure 4.

Discussion
The main objective to survey the current radiographic prescription in dental implant assessment was in order to determine the prescription pattern among the experienced dentists and whether dentists are using imaging modalities for implant placement as recommended by the AAOMR. Many options are available, from which the dentist can choose from.
However, the choice of radiography is determined by the advantages and disadvantages of each modality [10,11]. The pattern of radiographic choices and number of years of experience was similar to that observed in a study done by McCrea [12].
In the present study, the panoramic radiograph was the most frequent radiographic examination prescribed for treatment planning of Osseo-integrated implants. Approximately, 59% of dentists prescribed the panoramic radiograph, as a single examination technique and 41% of dentists combined it with a computed Tomography examination. The results of this study was in agreement with those obtained by Beason and Brooks [13], Sakakura, et al. [14], De Moraisetal [15].     The panoramic radiograph gives useful information in the initial evaluation for pre-operative planning, but owing to its large horizontal magnification varying regionwis. Another limitation is the lack of information in the third dimension [6-8]. An important aspect to be considered in the implant imaging prescription is the radiation dose. However in this study only 11% dentists looked on this reason for prescribing radiologic examination and the most observed reason for choosing the radiologic examination was its availability following by the measurement precision. This results are in consistent with that obtained by Majid et al. [16]. Although panoramic radiograph requires only a small radiation dose, it does not provide information in the third dimension, which is considered necessary by some [17]. Following the ALARA principle, for cross-sectional imaging the AAOMR [8], recommends conventional tomography for one to seven implant sites and CT for eight or more implant sites. The Cone Beam Computed Tomography (CBCT) is one of the more recent trends being used in radiography for implants [18].

Overestimation Underestimation Overestimation Underestimation
When comparing the frequency of over-and underestimated measurements of Panoramic radiography it was found that 50 % of dentists tends to underestimate and 34 % dentist overestimate the measurement. This fact can be explained by the presence of different levels of magnifi cation and distortion related to anatomical regions and lack of cross-sectional images [19,20]. Also, PAN presents a 2-dimensional image with no information about buccal-lingual thickness [1]. The image magnifi cation and the low reproducibility of alveolar canal diagnosis can increase the risks of anatomical structure damage to the inferior alveolar [13][14][15].
Our study also interviewed the % dentists using periapical radiographs and its reason. It was found that only a small percentage of dentists uses it during surgery and follow up whereas as majority of them tends to avoid it Peñarrocha M et al. [21], suggested that conventional periapical radiographs and digital radiographs were more accurate than panoramic radiographs in the assessment of peri-implant bone loss.
Periapical radiographs requires less radiation dose; produces minimal magnifi cation and a minimally distorted relationship between the bone height and adjacent teeth [8], making it a more convenient diagnostic tool in clinical practice. However it was overlooked by most of the dentists in our study.
Within the limitation of smaller sample size our study tries to emphasize the current radiographic prescription trends in the studied population.

Conclusion
This study has shown that the majority of dentists sampled prescribe panoramic radiographs for dental implant assessment based on its availability and only a small number strictly adhered to recommended guidelines of the world associations with regards to cross sectional imaging.