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 www.implantconcierge.com 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
Omaha
Nebraska 68105

https://dentistry.creighton.edu/directory/douglas-benn

http://omahadentalimaging.com/

www.implantconcierge.com

www.ReadCTs.com

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.

71-M-R-CACA

 

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 m.strever@implantconcierge.com 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 m.strever@implantconcierge.com or call us at 866-977-2228.

 

Implant Concierge Holiday Hours

CD6641_Z

 

 

As the holidays and the new year approach we would like to update you on our holiday schedule for the remainder of the year.

Christmas Week Schedule

We will be closed Wednesday the 23rd at Noon CST we will reopen Monday the 28th at 8:00am CST.

New Years Week Schedule

We will be closed Thursday the 31st and Friday the 1st. We will reopen on Monday the 4th at 8:00 CST.

 

Of course this doesn’t prevent us from providing amazing customer support. Feel free to email us at support@implantconcierge.com with any questions you may have. We will reply as soon as possible.

If you have any cases going to surgery within these time frames be sure to schedule your V.I.P. Meeting with enough time to ship your Surgical Guide to your place of business. We will be happy to work with you to insure a stress free surgery.

We appreciate the confidence you have placed in us and look forward to providing you with the best possible service. Please feel free to provide us with any questions, concerns or general feedback at any time.

Thank you and Happy Holidays.

 

 

 

 

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 support@implantconcierge.com!

 

 

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 www.implantconcierge.com 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!

douglas

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.”

rad

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

ADA Dental & Medical Codes for Services Provided by Implant Concierge

IC-Logo

After extensive research, Implant Concierge™ is excited to share Medical and Dental codes that will aide you in your efforts to obtain reimbursement for CBCT scans, radiology interpretations and even virtual surgical planning and CAD/CAM surgical guides.  Some of these ADA dental and medical codes are new, while others are new for both medical and dental.  Our goal is that by utilizing these codes, you will be able to implement Implant Concierge 3D services, thus providing a higher level of care for your patients.

More and more dental insurance carriers are recognizing that 3-D imaging is becoming the standard of care for certain dental procedures and thus, allow for reimbursement.  Did you know that the majority of Implant Concierge services actually fall under medical guidelines that are reimbursed through the patient’s medical insurance plan?  “Utilizing medical insurance instead of dental insurance for CBCT scans, radiology interpretations, 3D treatment planning and CAD/CAM surgical guides is a  wonderful opportunity to help your patient lower their out of pocket expenses while still allowing you to maximize the patient’s dental insurance for their subsequent restorative costs.  Very few dentists tap into their patient’s medical insurance and soley rely upon limited dental reimbursements.  We hope that these codes will allow you to provide more advanced dentistry for your patients while maximizing your reimbursements.”  Bret E. Royal, CEO Implant Concierge.

The following codes are listed for informational purposes, and do not guarantee member coverage or provider reimbursement:

Description ADA CDT Dental Code Medical CPT Code
Cone Beam CT for Maxilla D0382 70150
Cone Beam CT for Mandible  D0381 70110
Cone Beam CT For BOTH Arches  D0383 70486
Cone Beam CT of MandibleArch WITH Interpretation D0365 76376
Cone Beam CT of MaxillaArch WITH Interpretation D0366 76377
Cone Beam CT of BOTH Arches WITH Interpretation D0367 N/A
Reconstruction UsingExisting Data (Virtual Meeting) D0363 70486
Radiographic/surgical implant index, by report D6190 N/A
Radiologist Interpretation D9310 76140

 

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 www.implantconcierge.com or call us at (866)977-2228.

Continuing Education Courses for Guided Surgery for November and December

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 m.strever@implantconcierge.com 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?

 

 

November 11, 2015: Implant Direct

Where: Best Western Central Hotel, 800 East Park Drive, Harrisburg, PA 17111

Time: 6:30-8:30 pm

November 12, 2015: Implant Direct

Where: Best Western Lehigh Valley Hotel & Conference Center, 300 Gateway Dr., Bethlehem, PA  18017

Time: 6:30-8:30 pm

December 17, 2015: Implant Direct

Where: Riverside Dental, Dr. Michael Spencer, 1061 Riverside Ave, Jacksonville, FL 32204

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 m.strever@implantconcierge.com or call us at 866-977-2228.

 

Most Common Errors with the Dual Scan Protocol

In a previous post, we detailed the protocols to implement the “Dual Scan Protocol” (DSP) for fully edentulous cases. There are many benefits to using the DSP such as saving costs from having to duplicate the denture with a radio opaque material, the amount of time and the accuracy of a CAD/CAM surgical guide when the DSP is used correctly.

While the benefits are numerous and substantial, unfortunately, the DSP is by far the most widely rejected and trouble-some CBCT scan protocol for Implant Concierge referring dentists. Let’s spend some time reviewing the most common errors that we frequently see, and how it affects the accuracy and fabrication of a Fully Edentulous CAD/CAM mucosa borne surgical guide. Our goal by listing these common errors is to help our customers avoid these errors and help keep your Implant Concierge Guided Surgical cases stay on track and on time while minimizing unnecessary radiation exposure to your patients due to re-scans.

Problem

Reason

Example

 Denture has a “soft reline”.

If the patient’s denture does not fit well without adhesive or the soft-liner, then the surgical guide will not either.  The denture’s hard surface (hardliner) defines the soft tissue dimensions. A soft-reline denture does not provide the required information and will result in a rejected CBCT DSP scan or worse, will result in a poor fitting surgical guide and if used, inaccurate final implant position.

    dent with soft reline

 The CBCT scan with the denture presents “black air space” between the patient’s soft tissue and the denture.

Black space is a true indicator of either an ill-fitting denture or soft-reline material or both.  This is not acceptable and the CBCT scan will be rejected.

 

 den ill fitting 1den ill fitting 2

 Radiographic x-ray markers not positioned correctly.

Use six to eight, 1.0mm x-ray markers, randomly positioned in the “pink”

 Mandl Denture Only Front w background on sponge (00000002)Mandl Denture Only Linglual on w background on sponge (00000002)

 Denture is cut off in the scan

The entire denture must be captured.  Before releasing patient, ensure that the entire denture is captured in both CBCT scans.

 den cut off

 Denture is touching  a hard-surface or CBCT platform

Denture should not touch any other radiopaque material or hard surface, such as the CBCT platform.

 

Position denture on a 1” – 2” foam block or magic eraser so that denture appears to be “floating”.

 

 den on platflorm

 Metal present in denture [mesh repair]

Radio opaque material other than x-ray markers present potential challenges.  If metal support or mesh interferes with intaglio surface or creates excessive scatter, CBCT might be rejected.  Locator housings might cause problems, but not always.  This is determined by a case by case basis.  To be safe, duplicate denture in clear acrylic and add x-ray markers!

 denture with mesh
 

Markers are moved between scanning the patient with the denture and scanning the denture solo.

 

Take CBCT of denture only first, then take second CBCT of patient wearing denture.  Do not move the x-ray markers between scans, otherwise the merge of DICOM #1 and DICOM #2 will be unsuccessful.

  Using “flat” markers

Flat markers are common when using gutta percha as the radiopaque markers.  They should be rolled into a ball and adhered to the denture.  If they are smashed flat, we cannot see a difference in what is a marker and what is the denture.

 den with flat mark

 

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

Dual Scan Protocol: Scanning Protocol for Fully Edentulous Patients

Implant Concierge™ has simplified the workflow for fully edentulous CAD/CAM surgical guides!  No more impressions, no shipping master casts and no need to create expensive radiographic scanning appliances!

You may be familiar with older, time consuming and expensive protocols such as creating a duplicate denture with a complex barium sulfate mix or scanning the patient with an expensive radiographic prosthesis and shipping master casts across the country.  You no longer have to waste your time and money using these outdated protocols!  Instead, allow Implant Concierge™ to fabricate a fully edentulous mucosa borne CAD/CAM surgical guide based off a fast, easy, and affordable protocol called the Dual Scan Protocol.

The Dual Scan protocol, as the name implies, requires TWO CBCT scans.  To ensure success, it is imperative that your patient has a well-fitting, hard lined denture. Utilize six – eight ø1.0mm Suremark™ radiographic stickers positioned in a staggered axial pattern, sub-gingival (in the pink) and on both the buccal and lingual side of the denture, as shown here.

ld1        ld2

 

These x-ray markers are easy to use, because you can simply peel and stick them directly to the denture, eliminating the need to modify the denture by drilling 1.5mm spheres into the denture nor does it require the need to duplicate the denture with a radiographic substance.  Simply use the patient’s current denture!

Time for some CBCT’ing!  FIRST, scan the patient’s denture with x-ray markers.  Be sure to orientate the denture according to the occlusion (i.e. Maxillary teeth oriented down or Mandibular teeth oriented up) and rest the denture on a foam block so it is not in direct contact with the CBCT platform.  Finally, and it goes without saying, be sure the capture the entire denture in the CBCT field of view.

The second CBCT scan will be of the patient wearing the denture with the x-ray markers.  Do not remove or adjust the x-ray markers as positioned in CBCT Scan #1!  It is highly recommended that the patient wears a 1.0mm – 2.00mm thick bite registration during the CBCT scan to ensure an intimate fit of the denture to the soft tissue and in the desired occlusion.  Finally, be sure to capture the entire arch of interest in the CBCT scan.

After both CBCT scans have been acquired, upload both DICOM data sets directly to the Implant Concierge:

  •   CBCT #1 DICOM: Denture with six – eight radiographic markers fixated
  •   CBCT #2 DICOM:  Patient wearing denture with radiographic markers and bite registration

 

.Mandl Denture Only Front w background on sponge (00000002)     Mand Denture in mouth Zoom 2 (00000002)

“The Dual Scan Protocol has been a game changer for dentists and imaging centers alike!  No longer are treatment plans postponed due to waiting on labs to create clear acrylic dentures only to make the barium sulfate mixture too hot or gutta percha balls too large!  Plus, there is no need to ship master casts.  The dual scan protocol is faster, far less expensive and allows us to create an extremely well-fitting and accurate surgical guide – FAST!”

  • Bret E. Royal, CEO, Implant Concierge.

While the dual scan protocol is fast, easy and affordable, it is also the most likely CBCT scan protocol to be rejected by Implant Concierge 3D Customer Service agents due to not following these simple protocols.  The rejection of CBCT scans result in wasted time for both the dentist, patient and imaging center and results in unnecessary over exposure of the patient due to a second CBCT scan appointment!

To order a box of the 1.0mm SureMark radiographic stickers ($40 for 110 stickers) from Implant Concierge™, email us at support@implantconcierge.com or call us at 866-977-2228.  We will ship you a box straight to your office so you can start utilizing the Dual Scan Protocol for your fully edentulous patients!

The Implant Concierge™ 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.

For more information or to schedule a 15 minute demo, please visit www.implantconcierge.com or call (866)977-2228.