987 D3000 new imprint Word template Vol 13, No 1 (2025) ISSN 2167-8677 (online) DOI 10.5195/d3000.2025.987 http://dentistry3000.pitt.edu Barriers Toward Better CBCT Knowledge, Attitude, and Practice Amaal Alnuaimy1, Yasmin Mohammed2, Nagham Hussein Ali2, Ammar M. Sharki2, Faaiz Alhamdani2 1College of Den*stry, Al-Iraquia University, Iraq 2College of Den*stry,Ibn Sina University of Medical and Pharmaceu*cal Sciences, Iraq Abstract Objec?ve: This study aEempts to evaluate the knowledge, aLtude, and clinical pracOce of Iraqi denOsts toward CBCT use, referral paEerns, observed challenges, and the impacts of previous training on its adopOon. Material and Methods: A total of 202 Iraqi denOsts parOc- ipated in this study and self-administered quesOonnaires were distributed to them via Google Forms from 3/2/2025 to 1/4/2025. ParOcipants included both general pracOOoners (GPs) and specialists regardless of their years of experience in different dental fields. Results: Den- tal specialists showed significantly higher referral frequency for CBCT compared with GPs (P = 0.002). However, there was no significant relaOonship between gender and referral fre- quency for CBCT (P = 0.068), also, there were no staOsOcally significant differences were no- Oced in the specialists' responses in comparison to GPs about following guidelines for CBCT request (P = 0.167), having formal training on CBCT (P = 0.255), their adequacy of knowledge of CBCT (P = 0.293), and the need for CBCT training (P = 0.058). There was a significant differ- ence in the specialist responses compared to GPs about the necessity of CBCT in daily pracOce (P = 0.014). While there were no significant differences between both genders and years of pracOce (P = 0.138, P = 0.091), respecOvely, regarding the necessity of CBCT. Also, no signifi- cant relaOonship was found between both specialOes and age groups (P = 0.14, P = 0.839), respecOvely regarding the primary purpose of CBCT. A highly significant relaOonship has been found between being aspecialist versus GP and CBCT radiaOon dose compared to CT (P = 0.001). While no significant relaOonship when CBCT dose compared to orthopan- tomography (OPG) (P = 0.084). Conclu- sion: The major barrier toward beEer CBCT KAP was the lack of undergraduate training to CBCT imaging. IniOaOng a new educaOonal iniOaOves program and es- tablishing clear referral guidelines are crucial to fostering the effecOveness and ensuring the appropriate use of CBCT in dental pracOce across Iraq. Open Access Cita%on: Alnuaimy A, et al. (2025) Barriers Toward Be=er CBCT Knowledge, A@tude, and Prac%ce. Den%stry 3000. 1:a001 doi:10.5195/d3000.2025.987 Received: July 10, 2025 Accepted: August 26, 2025 Published: September 9, 2025 Copyright: ©2025 Alnuaimy A, et al. This is an open ac- cess ar%cle licensed under a Crea%ve Commons A=ribu- %on Work 4.0 United States License. Email: dr.amaalibraheem@gmail.com Introduc)on Cone beam computed tomography (CBCT) in dental imaging has revolutionized the pro- cess of diagnosis, treatment, and follow-up in dentistry because it offers three-dimen- sional visualization of oral and maxillofacial structures with a a reasonable dose of radi- ation when compared with traditional com- puted tomography (CT) imaging [1]. In many dental specialties like orthodontics, endo- dontics, maxillofacial surgery, and dental im- plants, CBCT become a crucial diagnostic tool. Many countries are implementing it now widely due to its ability to improve treatment planning and clinical outcomes. However, depending on many considera- tions like cost, accessibility, education, and training, its integration into routine dentis- try varies [2]. Despite of the beneJits of CBCT, concerns still exist regarding overuse, training, and refer- ral guidelines [3]. According to existing stud- ies which show that many dentists lack sufJi- cient education, proper training regarding its indications, radiation safety, and image interpretation which lead to inconsistent patterns of usage [4]. Although CBCT is a gold standard method for certain dental ap- plications, its usage should only be justiJied when clinically indicated to reduce radiation exposure to patients [5]. The availability and uses of CBCT technology are still limited in Iraq and there is a shortage of information regarding the knowledge, at- titude, and practice of Iraqi dentists toward this imaging modality. According to previous studies conducted in Iraq, a large number of dentists know the diagnostic advantages of CBCT but they have little access to training and education in this Jield. This gap is further exacerbated by the absence of formal educa- tion during undergraduate study programs in the universities [4]. Barriers Toward BeEer CBCT Knowledge, ALtude, and PracOce Vol 13, No 1 (2025) DOI 10.5195/d3000.2025.987 http://dentistry3000.pitt.edu 2 To the best of our knowledge, there are lim- ited studies on CBCT surveys conducted among Iraqi dentists to evaluate the impact of CBCT training on the attitudes of special- ists compared to GPs. The aim of this study was to evaluate the knowledge, attitude, and clinical practice of Iraqi dentists toward CBCT use, referral patterns, observed chal- lenges, and the impacts of previous training on its adoption. Material and Methods After obtaining the ethical approval of the re- search committee at the College of Dentistry of AI-Iraqia University. A total of 202 Iraqi dentists participated in this study and self- administered questionnaires were distrib- uted to them via Google Forms from 3/2/2025 to 1/4/2025. Participants in- cluded both general practitioners (GPs) and specialists regardless of their years of expe- rience in different dental Jields such as oral surgery, conservative dentistry, orthodon- tics, prosthodontics, and periodontics. The sample size was determined using data from a prior electronic questionnaire survey [4]. Responses were anonymized to preserve conJidentiality, and participation was en- tirely voluntary. The questionnaire was de- veloped after reviewing similar studies and validated survey tools [6,7] and reviewed by oral &maxillofacial radiologist and oral & maxillofacial surgeon who are experts in us- ing CBCT. It was composed of four sections: The Jirst section was the demographic infor- mation which includes age, gender, year of practice, specialty, and practice setting. The second section focused on the knowledge of CBCT use and radiation awareness. The third section was designed to address attitudes and referral practices. The fourth section in- vestigated the suggestions of the partici- pants to improve CBCT referral. Descriptive statistics were presented in terms of frequencies and percentages. Chi- square tests using the statistical package for social sciences software (SPSS V25) were used for analyzing the data. Results The majority of participants were males and under the age of 30 years. Regarding profes- sional experience, the highest percentage of participants had less than Jive years, and the lowest was between 11 to 20 years of expe- rience. Looking at dental specialization, GPs made up the majority of the survey. A total of 202 participants completed self-adminis- tered questionnaires in this analysis, repre- senting different dental professionals across Iraq. The sample includes diverse de- mographics in terms of age, gender, profes- sional experience, and specialization. The majority of participants were males and under the age of 30 years. Regarding profes- sional experience, the highest percentage of participants had less than Jive years, and the lowest was between 11 to 20 years of expe- rience. Looking at dental specialization, GPs made up the majority of the survey (Table 1). Table 1. Study demographic data. Study variable no. % age group <30 97 48 30-40 52 25.7 41-50 27 13.4 51-60 26 12.9 gender Male 126 62.4 Female 76 37.6 years of practice <5 88 43.6 5-10 44 21.7 11-20 27 13.4 >20 43 21.3 specialist vs GP General practi- tioner (GP) 109 54 Specialist 93 46 practice setting Private sector 55 27.2 Public sector 38 18.8 Academic insti- tution 100 49.5 Other 9 4.5 There was a signiJicant difference in the spe- cialist responses compared to GPs about the necessity of CBCT in daily practice (P = 0.014). While there were no signiJicant dif- ferences between both genders and years of practice (P = 0.138, P = 0.091), respectively, regarding the necessity of CBCT. Also, no sig- niJicant relationship was found between both specialties and age groups (P = 0.140, P = 0.839), respectively regarding the primary purpose of CBCT. A highly signiJicant rela- tionship has been found between being aspecialist versus GP and CBCT radiation dose compared to CT (P = 0.001). While no signiJicant relationship when CBCT dose compared to orthopantomography (OPG) (P = 0.084). The highest percentage of the responders thought that CBCT was occasionally needed in daily practice while the lowest percentage thought it was not necessary. Regarding the primary purpose of CBCT imaging, the ma- jority of the participants identiJied diagnosis and treatment planning as the main indica- tions. Most of the participants believed that CBCT radiation is only higher than conven- tional periapical (PA) radiography, and digi- tal PA radiography. It was interesting to note that 9.9% of partic- ipants believe that CBCT and digital PA imag- ing had the same radiation dose, and 8.9% of respondents thought CBCT emits a lower dose than traditional PA radiographs. The highest percentage of respondents believed that CBCT radiation is higher than OPG radi- ography and lower dose than traditional medical CT. The vast majority of the partici- pants thought that CBCT was useful for den- tal implant planning and the lowest percent- age thought it was useful for routine dental exams (Table 2). Dental specialists showed signiJicantly higher referral frequency for CBCT com- pared with GPs (P = 0.002). However, there was no signiJicant relationship between gen- der and referral frequency for CBCT (P = .068), also, there were no statistically signif- icant differences were noticed in the special- ists' responses in comparison to GPs about following guidelines for CBCT request (P = 0.167), having formal training on CBCT (P = 0.255), their adequacy of knowledge of CBCT (P = 0.293), and the need for CBCT training (P = 0.058). Most dentists reported that they rarely refer patients for CBCT imaging while the lowest percentage stated that they always made re- ferrals. More than half of the participants fol- lowed clinical guidelines before making the referral decision but they didn’t receive for- mal training on CBCT imaging and felt that the knowledge about CBCT imaging was in- sufJicient. Half of the participants attended a workshop on CBCT imaging referrals but they didn’t think CBCT imaging is over-uti- lized in their practice. The main challenge the participants faced in following guidelines for CBCT referral was lack of training while the main factor that inJluenced the decision for CBCT referral was the diagnostic neces- sity (Table 3). When participants were asked about sugges- tions to improve CBCT referral, over half of the respondents (51%) identiJied the imple- mentation of workshops or structured train- ing programs on CBCT indications and refer- ral protocols as the primary strategy. Discussion This questionnaire aims to assess awareness and knowledge of CBCT among Iraqi dentists Barriers Toward BeEer CBCT Knowledge, ALtude, and PracOce Vol 13, No 1 (2025) DOI 10.5195/d3000.2025.987 http://dentistry3000.pitt.edu 3 of different specialties and also to evaluate how their attitudes are affected by CBCT training and education. The fact that of a rea- sonable percentage of the respondents are academics reJlects their particular interest in educational aspect related to the subject. CBCT has an important role in diagnosis and treatment planning in dental practice [6-8]. It seems that the vast majority of respond- ents are aware of this fact. This is understood as CBCT is one of the radiographic assess- ment modalities. The primary aim of radiog- raphy in general is to complement the diag- nosis process. Any treatment plan depends on accurate diagnostic information that will signiJicantly enhance patient care, safety, and clinical outcomes [9]. Occasional use of CBCT as reported by the highest number of respondent might be be related to the fact that CBCT modality is not required in all daily practices cases. CBCT is usually required in only certain situations in oral and maxillofacial surgery, endodontics, orthodontics, periodontics, and restorative dentistry [10]. Other radiographic modali- ties such as OPG can provide the necessary required information in most cases. High cost of CBCT and high radiation dose to the patients might be additional factors [11,12]. The study showed that knowledge defects in CBCT are more obvious in the technical as- pect of CBCT machinery. Participants are not well informed about this technology com- pared to the more familiar conventional in- traoral and extraoral radiographic modali- ties and this may explain the discrepancy be- tween the participant responses regarding the CBCT dose compared to the literature. A high percentage of participants considered the radiation dose of CBCT was only higher compared to conventional PA and digital PA radiology respectively. Literature showed that CBCT had a much higher radiation dose [3]. Tamam et al study reported that CBCT has radiation dose is twice panoramic dental radiography [13]. It was, also, reported by this study that most of the respondents think that the radiation dose of CBCT was just lower compared to CT radiology, which contradict the literature. CBCT imaging for applications in dentistry produces much lower radiation doses than medical CT [1,14]. Specialist dentists, however, as the study conJirmed are more knowledgeable than GPs on CBCT knowledge techniques and referral frequency for CBCT. this conJirms the role of postgraduate education in different aspects of CBCT practice. A dentists with postgradu- ate qualiJication appear have more aware- ness of the role of CBCT and this could be at- tributed to the fact that postgraduate curric- ula focus more on advanced imaging techniques compared to undergraduate cur- ricula [15]. The fact that both gender and years of prac- tice do not a noticeable inJluence the attitude toward CBCT further conJirms that under- graduate studies focus more on conventional radiographic techniques [16]. Advanced ra- diographic techniques such as CBCT, CT scan and magnetic resonance imaging (MRI) lie out of the focus of undergraduate radiology subjects and this inJluences postgraduation practice [17]. As CBCT provides wide coverage of facial bones and teeth [18], CBCT is used as the standard imaging technique for several den- tal specialties, such as periodontology [19,20], orthodontics [21,22], oral medicine [23], oral and maxillofacial surgery [24,25], endodontics [26,27]. However, it was evident from the results of the current study that CBCT imaging most commonly was used for dental implant plan- ning which might be related to the fact that most of the participants practice dental im- plants. CBCT is a common place practice in dental implantology [28]. The highest per- centage of participants work in both public and private health sectors. Dental implant practice is commone in both the public and private sectors, which increases the possibil- ity to perform dental implant treatment. Furthermore, almost all dental implant courses dedicate part of their practical train- ing sessions to CBCT interpretation used for dental treatment. This Jinding aligns with the previous research [12]. This might explains why majority of dentists agreed that CBCT devices should be present in all dental clinics and believed that it was a helpful diagnostic tool in dentistry [4]. What might expaine that CBCT is not over utilized in dental practice is the belief that CBCT is not required in all dental situations. It also explains why the highest percentage of respondents rarely referred patients for CBCT imaging. Hazard of unnecessary radia- tion exposure might be one the reasons [29]. Inadequate knowledge in CBCT interpreta- tion might be another factor [30]. This fact is conJirmed by the European Academy of Den- tal Maxillofacial Radiology [5]. It worth men- tioning that over half of the respondents are GPs. The highest percentage of dentists who rarely refer patients to CBCT were GPS. Furthermore most of the participants didn’t receive formal training on CBCT imaging us- age, a fact conJirmed by other studies [4]. Participants felt that their knowledge about CBCT imaging was insufJicient. They have lit- tle or no instruction in the use and interpre- tation of CBCT imaging,. This result is in ac- cordance with the previous study [30]. The Jindings show that dentists are not well- informed on CBCT and that their under- standing of this exciting technology needs to be improved. Therefore, providing precise knowledge and training on CBCT to Iraqi dentists is crucial due to its widespread use and potential in several dental specialties. Patients today expect modern technologies and services from their doctors and dentists. The technology that CBCT gives the doctor not only has many beneJits for treating pa- tients, but it also has a notable factor because the 3-D images are displayed on a large screen for both the patient and the doctor to observe. The study's limitations included a self-reported questionnaire that may lead to bias. Conclusion The major barrier toward better CBCT KAP was the lack of undergraduate training to CBCT imaging. Initiating a new educational initiatives program and establishing clear re- ferral guidelines are crucial to fostering the effectiveness and ensuring the appropriate use of CBCT in dental practice across Iraq. References 1. Zaman MU. Comparing Radiation Doses in CBCT and Medical CT Imaging for Dental Applications. Journal of Pharmacy and Bioallied Sciences. 2024;16(Suppl 1):S883-S5. 2. Orth RC, Wallace MJ, Kuo MD, et al. C- arm cone-beam CT: general principles and technical considerations for use in interventional radiology. Journal of vascular and interventional radiology. 2008;19(6):814-20. 3. Jabbari N, Mousavi SR, Firoozi K. Comparative of radiation dose and image quality of Conventional Multislice Computed Tomography (MSCT), Cone-Beam CT (CBCT) and periapical radiography in dental imaging. Journal of Dental Medicine. 2016;28(4):334-42. 4. 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Journal of Dental Specialities. 2023;11(1):8-11. 30. Aditya A, Lele S, Aditya P. Current sta- tus of knowledge, attitude, and perspective of dental practitioners toward cone beam computed tomography: A survey. Journal of Oral and Maxil- lofacial Radiology. 2015;3(2):54-7. Table 2. Descriptive statistics for responses on CBCT knowledge. Study variable no. % To what extent do you think CBCT is necessary in your daily practice? Not necessary 6 3 Necessary to little extent 26 12.8 Occasionally needed 87 43.1 Highly necessary 61 30.2 Extremely necessary 22 10.9 What do you think is the primary purpose of CBCT imaging? Diagnosis 105 52 Treatment planning 89 44 Routine check-up 2 1 Other 6 3 What do you think about the radiation dose of CBCT compared to conventional PA radiography? Lower 18 8.9 About the same 15 7.4 Higher 103 51 Much higher 66 32.7 What do you think about the radiation dose of CBCT compared to digital PA radiography? Much lower 4 2 Barriers Toward BeEer CBCT Knowledge, ALtude, and PracOce Vol 13, No 1 (2025) DOI 10.5195/d3000.2025.987 http://dentistry3000.pitt.edu 5 Lower 7 3.5 About the same 20 9.9 Higher 96 47.5 Much higher 75 37.1 What do you think about the radiation dose of CBCT compared to OPG radiography? Much lower 1 0.5 Lower 19 9.4 About the same 50 24.8 Higher 108 53.5 Much higher 24 11.8 What do you think about the radiation dose of CBCT compared to CT radiography? Much lower 44 21.8 Lower 67 33.2 About the same 57 28.2 Higher 26 12.8 Much higher 8 4 Table 3. Descriptive statistics on attitude and referral practice toward CBCT. Study variable no. % On average, how often do you refer patients for CBCT imaging? Never 27 13.4 Rarely (1-2 monthly) 86 42.5 Sometimes (3-5 monthly) 55 27.2 Often (weekly) 25 12.4 Always 9 4.5 Do you consult clinical guidelines before referring a patient for CBCT imaging? No 37 18.3 Sometimes 51 25.2 Yes 114 56.3 Have you received formal training on CBCT imaging indications and usage? No 114 56.4 Yes 88 43.6 Do you feel your knowledge about CBCT imaging is sufHicient? No 138 68.3 Yes 64 31.7 Would you attend a workshop or training session on CBCT imaging referrals? No 45 22.3 Barriers Toward BeEer CBCT Knowledge, ALtude, and PracOce Vol 13, No 1 (2025) DOI 10.5195/d3000.2025.987 http://dentistry3000.pitt.edu 6 Maybe 56 27.7 Yes 101 50 Do you think CBCT imaging is over-utilized in your practice or region? No 102 50.5 Not sure 56 27.7 Yes 44 21.8