A Survey on Radiographic Prescription Practices in Dental Implant Assessment among Dentists in Kerala, India

Prabhath Ramakrishnan1, Faris Mohammed Shafi2, Anil Subhash2, Ajeya Kumara EG3, Jithesh
Chakkarayan4, Janisha Vengalath1
Department of Oral Medicine and Radiology, Kannur Dental College, Anjarakandy, Kannur, Kerala, India. 2Department of Prosthodontics, Kannur Dental College, Anjarakandy, Kannur, Kerala, India. 3Department of Periodontics, Kannur Dental College, Anjarakandy, Kannur, Kerala, India. 4Department of Orthodontics and Dentofacial Orthopaedics, Kannur Dental College, Anjarakandy,
Kannur, Kerala, India.
1

Abstract

Aims and objectives: To conduct a survey of the current radiographic prescription practices among implant practitioners in the state
of Kerala, India.
Methods: 300 dentists were interviewed by employing a questionnaire which enquired about the radiographic evaluation methods
prescribed by practitioners in implant site assessment in their implantology practice. Other reasons for choosing particular imaging
modalities were also enquired. The data collected from the survey was analysed using Epi-Info 7.1.3 software.
Results: Around 87.33% of the dentists prescribed only OPG for the implant site assessment and only 4.66% ordered Orthopantomograph (OPG) in combination with an Intra Oral Periapical Radiograph (IOPAR) and 4.33% ordered OPG with Computed
Tomography (CT). Only 0.02% of the practitioners ordered CT as a single examination and 1% ordered it in conjunction with other
modalities. 0.066% individuals ordered IOPAR as the sole imaging modality and none of them ever prescribed conventional or Cone
beam computed tomography.
Conclusions: Our study has conclusively proven that most of the dentists prescribe OPG followed by a combination of OPG and
Intraoral periapical radiographs in their implant practices. Many of them were not aware and did not follow the American Academy
of Oral and Maxillofacial Radiology, European Academy of Dentomaxillofacial Radiology, European Association of Osseointegration and International Congress of Oral Implantology recommendations regarding cross-sectional imaging.
Key Words: Dental implants, Radiography, Dentist practice patterns, OPG, Computed tomography

Introduction

of Dentomaxillofacial Radiology (EADMFR), European

Association of Osseointegration (EAO) and International
Congress of Oral Implantology (ICOI) [12-16]. A survey
conducted by Sakakura et.al, surveyed a group of dentists in
Brazil by using a questionnaire about radiographic prescription
practices and it showed that 68.3% of dentists prescribed
only OPG for dental implant assessment. Only 7.2% of
practitioners prescribed conventional tomography or CT as
a single examination, and 10.1% ordered it in combination
with other imaging modalities. The main reasons given for
prescribing OPG were broad coverage and cost (86.4%) [17].
Recent studies by McCrea and Shelley et.al conducted in the
United kingdom have also not shown any contradicting results
[6,18].
The recent position paper on the use of radiology in dental
implantology put forward by the AAOMR recommended that
cross-sectional imaging be used for the assessment of all dental
implant sites and that currently CBCT is the imaging method
of choice at present to gain this diagnostic information [13].
There is extremely scarce literature worldwide regarding
the radiographic prescription practices among implant
practitioners worldwide and whether they adhere to the
recommendations put forward by professional bodies like
AAOMR, EADMFR, EAO and ICOI [13-16].
It is also a cause for concern that there is absolutely no
literature of any sort reported from the Indian sub-continent,
where thousands of implants are placed each year, regarding

Dental Implants, widely used in the replacement of edentulous

spaces, have grown by leaps and bounds in the past few
decades, with newer advances in the field accelerating at
lightning speeds. The way dental practitioners have taken
to this technological advancement in oral rehabilitation
is really impressive. One of the main criteria in the
assessment of success in oral implants has been radiographic
measurement of marginal bone loss [1-3]. In the clinical
practice of implantology, radiographic imaging assists in the
preoperative assessment and treatment planning, surgical
procedure ,post operative evaluation and the ongoing implant
functioning. Many types of radiographic modalities are used
in implantology namely, Intra-Oral Periapical Radiography
(IOPAR), Orthopantomography (OPG), occlusal radiography,
Conventional tomography, Computed Tomography (CT) and
Cone-Beam Computed Tomography (CBCT). Usually, it is
the practicing clinician who decides which modality best suits
him and his needs [4-10].
Beason and Brooks [11] surveyed the different imaging
modalities used in implant site assessment in a random group
of practitioners in Michigan, USA and the results showed
that 95% of them take OPG for at least 80% patients and
90% said they never prescribed any form of cross-sectional
imaging contrary to the recommendations put forward by
the professional bodies like American Academy of Oral and
Maxillofacial Radiology (AAOMR), European Academy

Corresponding author: Prabhath Ramakrishnan, Department of Oral Medicine and Radiology, Kannur Dental College, Anjarakandy,
Kannur, Kerala, India; Tel: 00919746556779; e-mail: [email protected]
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Results

radiographic prescription practices for implant site assessment.

Hence, we thought it prudent to conduct such a survey among
implant practitioners.

The results are exhibited in Figures 1 and 2 and in Table 1.

The radiographs most commonly prescribed were the OPG
(87.33%) followed by OPG plus IOPAR (4.66%). The next
modality was a combination of OPG and CT scans (4.33%)
followed by a combination of OPG+IOPAR+CT (1%).
Approximately 0.02% of the practitioners prescribed CT
scan as the sole imaging modality and only a meagre 0.066%
used IOPAR alone for assessment (Figure 1). None of the
practitioners mentioned opting for conventional tomography
or Cone Beam Computed Tomography (CBCT). When
enquired about the reason for prescribing certain modalities
the main reason was broad coverage of facial bones and
teeth (65.33), followed by measurement precision (7.33%),
availability (5.66%), Cost (1.66%) and patient radiation dose
(1%) (Figure 2)
Table 1 depicts the reasons given for prescribing each
specific examination or a combination of multiple modalities.
The main reason why practitioners chose OPG was because
of the broad coverage (69.84%) and a combination of cost
and availability (12.59%). None of the practitioners advised
a conventional tomography or a CBCT and hence it was not
included in the final data analysis (Table 1).

Materials and Methods

300 dentists were randomly interviewed by employing

a questionnaire which enquired about the radiographic
evaluation methods prescribed by practitioners in pre and
post operative assessment in their implantology practice.
All of the dentists involved in the study were specialised
or trained in implant dentistry and included specialities like
Oral and Maxillofacial Surgery (35.4%), Prosthodontics
(32.8%), General Dentistry (12%), and Periodontology
(19.8%). A close ended questionnaire was given to the
dentists participating in the study and data collected regarding
the radiographic prescription practices for pre operative
implant assessment and follow up, like OPG, Conventional
tomography, CT, and OPG. They were also asked regarding
whether combination modalities were used in assessment.
The questionnaire also enquired about the reasons for the
particular imaging modality being chosen like Cost, Patient
radiation dose, Broad coverage of facial bones and teeth,
availability, and measurement precision. The data was also
analysed to ascertain if a combination of these reasons
affected their judgement in choosing the imaging modality.
The data collected from the survey was analysed using EpiInfo 7.1.3 software and the results determined.

Discussion

We decided to conduct this survey which was the first of

its kind in the Indian subcontinent to survey the current
radiographic prescription practices in Dental Implant

90%
80%
70%
60%
%

50%
40%
30%
20%

Figure 1. The distribution of the

various imaging modalities in implant
site assessment. 1. IOPAR; 2. OPG; 3.
CT; 4. OPG+IOPAR; 5. OPG+CT; 6.
OPG+IOPAR+CT.

10%
0%

Various imaging modalities employed

70%
60%
50%

40%

Figure 2. Distribution of the reasons for

prescribing particular imaging modalities for
assessment of implants. 1. Cost; 2. Patient
radiation dose; 3. Broad coverage of facial
bones and teeth; 4. Availability; 5. Measurement precision; 6. Cost+availability; 7.
Cost+broad coverage; 8. Cost+precision.

30%
20%
10%
0%

Main reasons for choosing imaging modality

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Table 1. The distribution of the different imaging modalities chosen by various dentists in implant site assessment.
The different types of radiographic examinations prescribed for dental implant assessment
Radiographic examination employed
IOPAR
1
0
0
1
0
0
0
0
OPG
4
3
183
11
9
33
12
7
CT
0
0
2
0
4
0
0
0
CONV.TOM
0
0
0
0
0
0
0
0
OPG+IOPAR
0
0
4
5
0
5
0
0
OPG+CT
0
0
6
0
7
0
0
0
OPG+IOPAR+CT
0
0
1
0
2
0
0
0
Total

assessment and whether they are aware of and follow the

recommendations put forward by the American Academy
of Oral and Maxillofacial Radiology (AAOMR), European
Academy of Dental and Maxillofacial Radiology (EADMFR),
European Association for Osseointegration (EAO) and the
International congress of Oral Implantologists (ICOI) [13-16].
As per the AAOMR recommendations OPG may be
used for the initial assessment and an IOPAR can be used to
supplement the preliminary information from the OPG. Initial
diagnostic information should not be gleaned from a Cone
beam Computed Tomography (CBCT) [13]. The EADMFR
guidelines put forward 20 basic principles for the use of
dental CBCT where they have also mentioned that CBCT
examination is justified only if it adds new information to the
patients existing condition [14]. The EAO has recommended
that clinicians should decide if cross-sectional imaging is
required or not based on the information from conventional
radiography. They have recommended that if cross-sectional
imaging is warranted, then the case must be referred
to specialist dentomaxillofacial radiologist. They have
recommended that fundamentally proper clinical examination
must be performed with recommended standard radiographs
before deciding if cross-sectional imaging is indicated [15].
The ICOI recommended that the benefits from subjecting
a patient to CBCT examination must outweigh the risks and
should not be taken without obtaining proper medical and
dental history and performing thorough clinical examination
of the sites. The radiographic modality should be tailored
to individual needs and the smallest possible Field of View
(FOV) must be used [16].
In this survey conducted in the state of kerala in India, we
have ascertained that the OPG, mostly solely, was the most
frequent imaging modality chosen by the implant dentistry
practitioners for their implant practices. Approximately a
huge 97.3% of the practitioners preferred an OPG examination
either as a single imaging modality or as a combination with
other imaging modalities. This proved that they have all not
been following the international AAOMR, EADMFR, EAO or
ICOI recommendations, about which 98% of the practitioners
were not even aware of our study has shown similar results
as Beason and Brooks; and Sakakura et al. where 95% and
82.6% practitioners respectively chose OPGs in their implant
practices over other modalities contrary to the AAOMR and
EADMFR recommendations [11,13,17]. McCrea performed
a study involving members of the British Society of
Periodontology, which enquired about the adherence to EAO
guidelines. Clinicians using other cross-sectional imaging
were in minority namely, Linear tomography-8%, multi-

Total
2
262
6
0
14
13
3
300

directional Tomography-25% and Cone Beam Computed

Tomography-2.5% [6]. A recent study by Shelley et.al showed
no agreement among practitioners about image prescription
methods which is similar to the results obtained by us [17,18].
Similar to Sakakura et al. study, more than half of the dentists
(65.33%) prescribed OPG, due to broad coverage of the facial
bones and teeth (69.84%), followed by cost and availability
(12.59%). Because of a substantial number of people have
chosen cost over other factors, we assume that cost plays
an important role in addition to the need for diagnostic
information by the practitioners, which maybe because india
is still an economically developing country when compared
to other developed counterparts. Most of the practitioners
we believe would be performing this procedure without
proper cross-sectional information. They rely on their clinical
judgement to assess the bone width and many a time this may
result in bad prognosis for the implant because of the lack
of sufficient bone in terms of quantity [19]. In our study we
came to know that only 6 practitioners (0.02%) of our sample
ever prescribed a cross-sectional imaging modality for their
cases. In this case all the practitioners made use of Spiral CT
scans and no one ever prescribed a conventional tomography
or a CBCT for their patients. This is very similar to the study
by Beason and Brooks where more than 90% of the dentists
had never used conventional tomography and 65% had never
used CT, and is also similar to the study by Sakakura et al.,
where only 7.2% of the dentists prescribed conventional
tomography or Computed Tomography (CT) as a single
examination and 10.1% prescribed CT in combination other
types of radiographic examination bringing the total upto
17.3% [11,17]. McCrea also conducted a postal questionnaire
similar to ours in which the practitioners were quizzed
regarding their knowhow of the guidelines put forward by
professional bodies, out of which 208 clinicians (80.8%) did
not follow UK selection criteria for single sites and around
217 clinicians (77.5%) did not follow the criteria for multiple
sites. In addition to 263 clinicians (94%) did not follow the
USA selection criteria. They concluded that around 80% of the
participants in the survey were not following the guidelines for
pre-implant imaging. The author was of the opinion that there
is a need for research and formulation of selection criteria that
will be prescribed by practitioners of implantology [6]. In the
recent study by Shelley et.al 169 dentists were surveyed which
showed no consensus among practitioners on radiographic
prescription practices. Implantologists who placed more than
100 implants per annum were not using imaging guides and
often used similar views for implant site assessment. Those
who had a Cone Beam Computed Tomography (CBCT)
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machine often used it without actually considering whether the

case was indicated for the examination or not. They concluded
that there was a need for the formulation of evidence based
criteria for radiographic prescription which had to be widely
disseminated among practitioners by educating them [18].
OPG provides an excellent general overview of the dentition
and the jaws. But, they have certain inherent limitations when
used for pre and post implant assessment like distortions in
the horizontal plane, magnification in the vertical plane and
the image is only a two dimensional representation of a three
dimensional entity. Important anatomical structures like the
Inferior alveolar canal are also not well demonstrated on the
OPG. Another drawback is that images closer to the lingual
cortex may many a time be superimposed at a higher level in
the radiograph not to mention the numerous airway shadows,
Ghost images and soft tissue shadows which can adversely
affect treatment planning [20-22].
We feel the main reasons for not prescribing a crosssectional imaging modality by most of the practitioners is
because of the lack of awareness of the recommendations of
the AAOMR, EADMFR, EAO or ICOI and also due to the lack
of availability of conventional tomography or CBCT in the
state of kerala. During the drafting of this article it has come
to the knowledge of the authors that the first CBCT centre is
being set up in kerala state by a private practitioner and there
is no such apparatus available for mass use in the government
sector. The non-availability of the imaging modality, coupled
with the dentists familiarity with assessment of an OPG
image and lack of knowledge about cross-sectional imaging
may all be factors contributing to the poor prescription of cross
sectional imaging for dental implant site assessment. Around
18.99% of the practitioners have mentioned cost with other
factors like availability, broad coverage and measurement
precision as concerns which affected their judgement. In a
developing third world country like India it is only a small
percentage of the population who can go for a costly treatment
option like an implant. The costs involved in cross-sectional
imaging may add to this burden causing practitioners to
forego cross-sectional imaging techniques and rely more on
their clinical acumen and expertise in implant placement.
Similar to Sakakura et als study, 3 dentists (1%) considered
radiation dose to influence their prescription [17]. Similar
to dental schools internationally, Indian dental schools also
stress a lot on dose reduction by following the ALARA (As
Low as Reasonably Achievable) principle. But, definitely the
lowest dose possible should not be achieved at the cost of poor
diagnostic information. This would also lead to practitioners

requesting a repeat radiographic examination increasing the

cumulative irradiation to the patient.
The AAOMR recommends that although intial imaging
assessment maybe achieved with OPG supplemented with
IOPAR, for preoperative diagnostic assessment a crosssectional imaging be used for implant site assessment [13].
They also recommend CBCT as the imaging modality of
choice because very minimal radiation dose can provide the
greatest diagnostic yield which should be the hallmark of any
radiographic imaging modality. However, for periodic post
operative implant monitoring, IOPAR and OPG cases would
be able to provide adequate diagnostic information. In India
similar to other countries the interpretation of CBCT images
is done by specialist oral and maxillofacial radiologist who
also specialises in oral medicine. These specialists are few in
number and the general dentist is not trained to interpret crosssectional images which maybe a cause for the reduced number
of referrals. Small changes in the dental education curriculum
can change all that. This is already being implemented in the
curriculum prescribed by the Dental Council of India where
maxillofacial radiology is being taught at the undergraduate
level itself. The use of CBCT in implant imaging seems to
be very promising however there is a need for more research
on the efficacy of CBCT in assessment of the implant site.
Currently there has not been any large scale standardised
trials involving CBCT use and implant success or failure
anywhere in literature and would be a good avenue to direct
further research. To conclude, this survey has shown similar
results as that of Beason and Brooks Sakakura et.al, McCrea
and Shelley et.al where the majority of the dentists in kerala
state in india prescribe OPG as both an initial and final
diagnostic modality for dental implant assessment based on
broad coverage, cost and availability and are not following the
recommendations and guidelines put forward by professional
bodies engaged in the practice of Implantology [6,11,17,18].
Approximately 98% of the practitioners were not even aware
of recommendations existing for proper implant radiology
practice. We feel there is a need to develop a broad evidence
based criteria for radiographic prescription in implant site
assessment and this has to be introduced in the current
dental school curriculum throughout the world. For this to be
possible , data from different regions of the world regarding
radiographic prescription practices must be collated and all
the professional bodies located around the world; not just the
US and UK have to collaborate to put forward a consensus
paper establishing guidelines for radiographic implant site
assessment.

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