Congenital fusion C2-C3 vertebra and degenerative changes

Chance findings in a 57 year old male. In the axial slice a joint space can be seen on the right side (“C2-3 joint”). On the left side an enlarged well defined round opacity can be seen with variable internal density – yellow arrow (“C2-3 joint fused”). This is primary congenital fusion of the joint C2-3  with consequent degenerative process with hyperostosis. There is also hypogenesis of the left C1-2 joint – large space between C2 lateral pedicle marked by red arrow (“C1-2 hypogenesis”). Look at the right side to see a normal C1-2 joint. The C2-3 enlargement reflects advanced degeneration in course of congenital deformities (secondary to chronic change of the physiological function).


C2-3 joint

Any CBCT with an abnormality like this should be referred for confirmation that this is a benign finding.

Apical Infection and Heart Disease

Association Between Chronic Apical Periodontitis and Cardiovascular disease


It has been suspected for over 100 years that oral sepsis is associated and probably causes many systemic diseases (Hunter 1900). In recent years there have been many papers describing strong associations between chronic periodontal disease and cardiovascular disease (REVIEW: Hayashi et al 2010). The dental profession is becoming aware of the importance of preventing and treating chronic periodontal diseases. However, less well known is the association between chronic apical periodontitis and cardiovascular disease (CVD). In 2012 Pasqualini D et. al. published an important paper showing an association between apical periodontitis and CVD which makes perfect sense since many of the same organisms found in periodontal diseases are found in apical disease.


For many years, as a radiologist, I have seen and reported on the presence of apical radiolucent areas as “probably apical granuloma and possibly a radicular cyst” as shown in the images below of two lesions seen in the same patient.

Apical granuloma

Fig 1 #30 mesial apex with 5 mm lucency.

Apical granuloma 1a

Fig 2 #30 mesial apex with thin panoramic slice to reveal the true extent of the lucency.

Apical granuloma 2


Fig 3 Same patient as figs 1 and 2 #3 mesiobuccal apical lucency 6 mm in diameter with associated mucosal thickening of the floor of the right maxillary sinus

Recently I have decided that the research literature is showing such high association between oral infections and other systemic diseases that I would be failing in my reports just to state that oral sepsis is present. When I see a large cyst or possible malignant tumor I always add a recommendation such as “a biopsy and/or consultation with an oral surgeon is advised.” Carotid artery calcifications I recommend “the patient and their MD should be informed” so that they can decide if an ultrasound examination is needed. Apart from providing the best care for the patient it also ensures that you avoid the possible legal situation of failing to diagnose and appropriately deal with a serious medical condition. With regard to apical lucencies I now write “There is an association between chronic apical periodontitis and coronary heart disease (Pasqualini D et. al. Association among Oral Health, Apical Periodontitis, CD14 Polymorphisms, and Coronary Heart Disease in Middle-aged Adults. Journal of Endodontics 2012 38 (12) 1570-1577).”


“The times they are achangin” (Bob Dylan 1964)…….



Hunter W (1900). Oral sepsis as a cause of disease. Br Med J 2: 215.

Hayashi C et. al. (2010). Pathogen-induced inflammation at sites distant from oral infection. Molecular Oral Biology 25 305-316.

Pasqualini D et. al. (2012) Association among Oral Health, Apical Periodontitis, CD14 Polymorphisms, and Coronary Heart Disease in Middle-aged Adults. Journal of Endodontics 38 (12) 1570-1577.


Dr. Douglas K Benn
3610 Leavenworth Court
Nebraska 68105

Tel: 402-953-6264

Degenerative Joint Disease of the Cervical Spine

Degenerative joint disease is common in the Temporomandibular and other joints such as the cervical vertebrae. This 71 year old gentleman has a chance  finding of a well-defined opacity in the mid-line in close proximity to the anterior surface of the odontoid process of C2. This is most likely an osteophyte or calcification of the anterior median ligament. It is of no clinical importance.  Degenerative joint disease is related to age and most people over the age of 50 years have visible signs of degenerative joint disease such as the osteophyte labeled for C1.

benn 1

Panoramic Discrepancies on Atrophic Mandible Ridge

Panoramic radiographs are good for a general assessment of jaw bone size and teeth / anatomical structures. However, the inherent magnification and difficulty of placing the jaws inside the focal trough, together with lack of third dimension can produce significant problems in assessing bone morphology. The panoramic  image Figure 1 below of a 76 year old lady shows a moderately atrophic mandibular ridge  but there does appear to be bone above the mylohyoid ridge in the posterior regions. However, in Figure 2  the reformatted CBCT panoramic shows none on the left and  a little on the right.


dr been 1


Tracing of the inferior alveolar nerve canal in figure 4 shows the mental foramen at the level of the alveolar ridge.


dr benn 2

In Figure 5  cross sections across the mandible show the left mental foramen opening onto the ridge crest and a lingual knife edge ridge running from the mental

foramen region posteriorly. A similar appearance was found on the right side. None of this was apparent from the panoramic image although an experienced

clinician might be suspicious of the apparent panoramic ridge height .

dr been 3

If you are planning implants cross sectional CBCT should always be performed after your initial pan assessment.



Dr Douglas K Benn BDS, M Phil, DDS, PhD, Diplomate of Dental Radiology (Royal College of Radiologists, England)
Professor of Oral and Maxillofacial Radiology
Creighton University School of Dentistry
Boyne room 207
2802 Webster Street • Omaha NE • 68178
Tel: 402-280-5025

American Academy of Dental Group Practice Event

Our CEO, Bret E. Royal, will be attending the 2016 American Academy of Dental Group Practice Event, taking place Thursday, February 3rd to Saturday, February 6th in Las Vegas, Nevada!

Take a moment to stop by the Implant Concierge booth, #528, and say hi to Bret! He will be there to answer any questions and looks forward to meeting some of our fellow doctors, and of course our potential new doctors!

Implant Concierge hopes to see you there. Have a great meeting!

For more information, please visit:

How To Read A CAT Scan

Quiet often, I am asked by dentists if they should get a Board Certified Radiology Interpretation on every CBCT scan.  Since I am not a lawyer, a dentist or an expert, I really can’t answer that question.  However, I always mention to a dentist that if they do not feel comfortable reading a CBCT scan, then it only seems logical that they should get an expert to review their CBCT scan.  With that being said, less than 10% of all CBCT scans acquired at our imaging centers and new cases started at order an interpretation.

I am surprised by this number, but also thankful because honestly, there aren’t enough radiologist to handle the workload if EVERY CBCT scan taken required a radiology interpretation!  The wait for an interpretation would be months!!  It is common for dentists to provide their own general review and if they see something that catches their eye, then they will order an interpretation.  Of course then, the next question is, “Is there a recommended process or official manner to read a CBCT scan?

To answer this question, Dr. Douglas Benn, one of our radiology partners and XXXXX at Creighton University has created this outline to help a dentist review their own CBCT.

Thank you Dr. Benn!


“A structured approach is required as there is a huge amount of anatomy contained within the scanned volume and unless a careful systematic approach is used then it is likely that you will miss something. My advice is:

  1. Review the clinical history, medical history, chief complaints. Know which teeth have been removed in the last few months to explain areas of bone loss with healing/ disrupted bone. Know if bone grafts are present and date of surgery.
  2. Review the axial slices starting with the anterior superior region (Frontal sinus), move down through the jaws and anterior face until you reach the cervical region. Then concentrate on the airway and spine and move up to the cranium. In this way you will cover the whole region. DO NOT THINK ABOUT THE CHIEF COMPLAINT  as this will bias you away from looking at all  the other areas.
  3. Now read the coronal slices from front to back and come back to the mental region.
  4. Lastly sagittal slices from right to left.
  5. Create a panoramic tomograph view and count how many teeth are missing.
  6. Adjust the field of view so you are only looking at the maxilla and in panoramic cross section work from right to left. Carefully examine all apices for widening of PLS, enlargement of the nasopalatine canal and presence of maxillary sinus bony septa as these should be avoided when performing sinus lifts.
  7. Adjust the field of view so you are only looking at the mandible and in panoramic cross section work from left to right. If implants or removal of third molars are planned, trace the inferior alveolar canals. Again check apical areas. In the midline search for the lingual canal if anterior implants are planned to avoid cutting these vessels. A simple arrow can be used to note the position of the canals.
  8. Lastly examine the region/s of the chief complaint/s and note abnormalities.
  9. Allow plenty of time. An average adult 40 years of age with most of their teeth and 2-3 root canals will take at least 20 minutes including make copies of selected slices of interest. A patient with large restorations and multiple root treatments (5+) is likely to take at least 40 minutes as the probability of apical pathology is high.

rad update

The time spent will reward you handsomely as your treatment planning will be more thorough and you will avoid pitfalls of providing implants next to diseased teeth.”

Dr. Douglas K Benn DDS PhD, Diploma in Dental Radiology (Royal College of Radiologists, England)

Oral and Maxillofacial Radiologist
3610 Leavenworth Court
Nebraska 68105

Diagnosis and Management of Dental Patients With Suspected Carotid Artery Calcification

Read our newest blog from one of our Board Certified Radiologists in Nebraska!

Dear Colleagues,

I thought it would be helpful to elaborate on the diagnosis and management of patients who have chance findings on panoramic and CBCT radiographs which are suggestive of calcification of the Carotid arteries. In adult patients who do not have chronic renal disease the chance of seeing an irregular shaped and variable density opacity at the level of C3- C4 in the parapharyngeal regions is about 4-5% of radiographs. If the patient is a smoker with a known history of cardiovascular disease then chances increase of finding a calcification.

Patients with Chronic Renal disease have a 50% prevalence of carotid artery calcification on radiographs. In the average general practice of about 1,500 people with 50% being adults then about 30 people are likely to have carotid artery calcifications  so you should definitely see this condition in your office population.

In this CBCT image of a 71 year old male with known problems of cardiovascular disease and hypertension,  a 4 mm opacity appeared with 2 distinct white lines which are compatible with calcification of the walls of the carotid artery. The carotid artery bifurcation is about 6 mm in diameter.

A letter was sent to the patient’s MD regarding the need for further evaluation and the possible complications for the planned tooth extractions. A Doppler ultrasound examination was performed and calcification of the Internal Carotid artery was found bilaterally. The Internal carotid artery is smaller than the Common Carotid which explains why the calcification measured 4 mm.

The ultrasound reported a narrowing of the artery lumen of between 1-49% and as such is not producing a significant reduction of blood flow. The MD recommended that provided a general anesthetic (GA) was not planned for the extractions then no special precautions were necessary. However, an EKG should be performed prior to any GA.
In this particular case the patient was already under medical care for cardiovascular disease and associated hypertension  reducing the likelihood of stroke or heart attack. However, in patients with no history of cardiovascular or renal disease, the finding of a carotid artery calcification can be an alarm signal indicating that it is important to inform the patient and their MD as there is likely to be occult cardiovascular disease with the possibility of sudden death from a heart attack or a stroke.



Dr. Douglas K Benn


Continuing Education Courses for Guided Surgery:: January 2016

implant direct

Guided Surgery: Core Principles & Technologies

Implant Concierge™ is excited to announce several upcoming Continuing Education courses with Implant Direct! Please see the list below for a city near you! For $50, you will receive 1.5 hours of CE and dinner! Seating is limited. RSVP quickly at or call 866-977-2228.


Course Objectives:flyer pic 2

  • Providing simplified processes and flow charts
  • Minimizing steps, materials, and costs
  • Integrating IOS/.stl files, RPD’s and existing dentures
  • Reviewing software and instrumentation options
  • When to use guided surgery? How much to charge?



January 19, 2016: Implant Direct

Where: Rosa Restaurant, 70 State Street, Portsmouth, NH 03801

Time: 6:30-8:30 pm

January 20, 2016: Implant Direct

Where: 111 Memorial Road, West Hartford, CT 06107

Time: 6:30-8:30 pm

January 21, 2016: Implant Direct

Where: Tosca, 14 North Street, Hingham, MA 02043

Time: 6:30-8:30 pm

flyer pic 1

If you do not see a course close to you, and would like to have a course created in your area, please contact us at or call us at 866-977-2228.


Video: Creating your first Implant Concierge Case

Implant Concierge is excited to announce the release of our newest “How To” video! Please review the video shown below on How to Create a Case for Implant Concierge! If you have any additional questions or comments, please feel free to call us at 866-977-2228, or email us at!



The Implant Concierge™, a San Antonio, TX based company, is a free, web-based proprietary software that enables any dentist who places implants to utilize the known advantages of guided surgery immediately without purchasing expensive software, going through time consuming weekend training courses or spending hours after or during work trying to coordinate and plan their next guided implant case.

The Implant Concierge™ automatically communicates through our HIPAA compliant portal with all of your implant team by synchronizing all steps seamlessly and efficiently for you.  We work hard to synchronize your case so you can keep your hands in the mouth and not on a mouse!

For more information or to schedule a demo, please visit or call us at (866)977-2228.

Welcome Dr. Douglas Benn- New Board Certified Radiologist

Implant Concierge is excited to announce that as part of our services and education, we have added Dr. Douglas Benn as one of our Radiology Providers!

Dr. Douglas Benn trained as a dentist at the London Hospital Medical College and worked for 10 years as a general dentist specializing in minor oral surgery and treatment of the severely handicapped. During this time he completed a Masters in Computer Science. He then spent 6 years in the Department of General Dentistry and Public Health, University College London and was awarded a PhD for investigating new methods for diagnosing Caries and the Periodontal Diseases. Following this Dr. Benn trained as an Oral and Maxillofacial Radiologist at Guy’s Hospital London and the Royal College of Radiologists.

 In 1992 he was appointed as a Professor at the University of Florida. From 2000-2002 he was Editor-in-Chief of the peer reviewed journal Dentomaxillofacial Radiology. During 1996-2002 he led a team developing an automated caries risk assessment and treatment planning system based upon an electronic patient record. He has published over 50 peer reviewed research papers. In 2009 Dr Benn was appointed Professor and Director of Oral & Maxillofacial Radiology at CUSD. Currently he is developing a new radiographic method for differentiating between cavitated and non-cavitated carious lesions which is funded by the National Institutes of Health. Dr. Benn is an NIH Study Section reviewer for [MOSS-K 11]. He is the inventor on several patents.

In addition to providing another first class radiological option for our customers to choose from, Dr. Benn will also share a case every month.  These cases will be based not just from a dental perspective, but will also focus on medical concerns.  We hope that our monthly case submission will be interesting and very educational for each of you!


Dr Douglas K Benn BDS, DDS, M.Phil., Ph.D., Diplomate in Dental Radiology (Royal College of Radiologists, England)

Professor and Director of Oral and Maxillofacial Radiology, Dept. Diagnostic Sciences, Creighton University


Title:  Base of tongue swelling

A 57 year old lady was recently being treatment planned for dental implants. Upon evaluation of the full volume a soft tissue swelling 8 x 10 mm was noticed in the left base of tongue region occluding part of the space between the left posterior side of the epiglottis and the tongue.

Any obvious asymmetries like this should be reported to the patient and their MD informed since an ENT examination is indicated. There has been an increase of base of tongue cancers over the last few years which may be linked to HP virus. These are not rare and thorough inspection of the pharyngeal airway region should always be performed.”


If you have any questions, comments, or concerns, please let us know at or by calling us at 866-977-2228. You may also tweet us at @CBCTmade easy, or ask us on Facebook!