This 56 year old female patient presented last year with primary symptoms of a chronic, long-standing (two years)
left maxillary sinusitis and vague dental pain in her ULQ.  She had been on multiple rounds of antibiotic regimens
and was considering functional endoscopic sinus surgery at the recommendation of her ENT.


Percussion of both #13 and #15 were positive which were difficult to interpret being joined by the bridge and in such
close proximity to the sinus.  Also, multiple radiographs were difficult to read due to the zygoma and low palatal vault.
Furthermore, I was not comfortable relying on the negative cold response in #15 through the ceramic restoration, as her
other crowned teeth were also barely responsive to cold stimuli with endo ice.

I sent this patient for an iCat (digital CT scan) requesting specific cuts of tooth #15.  The image shows significant
mucosal edema in the floor of her left maxillary sinus and faint evidence of a periapical radiolucency on the palatal
root of #15 which was difficult to recognize on her PA radiograph.  I suspected MSDO (maxillary sinusitis of dental origin).


Root canal therapy was recommended for tooth #15 and the access cavity was performed without anesthesia as a test.
There was minimal response to drilling and a necrotic pulp was found upon access.  Root canal therapy was completed.


The patients sinusitis symptoms resolved within just a few days after endodontic treatment and have not returned.
I recently sent her back for a one-year follow up iCat image to compare to her original.


The floor of the sinus shows healthy mucosal tissue with no evidence of edema.  She has remained symptom free since her
root canal therapy.  No further adjunctive sinus treatment has been performed - Rod

Really neat, Rod.  I'm betting a ton of sinus surgery is done due to PA pathology.  Guy

Guy, It is generally accepted in the medical literature that 10-15% of maxillary sinus pathology is secondary to dental infection.  Some studies
have shown it could be much higher – One found 40.6% and another found 47% of chronic sinus infections to be secondary to dental pathosis.

Approximately 350,000 sinus surgeries are performed annually in the U.S.  These are typically last resort treatments on long-standing chronic
rhinosinusitis cases that have failed to respond to multiple antibiotic regimens.

Some sinus surgeries are very necessary; deviated septums, cysts, polyps etc can block the ostium and inhibit proper drainage.  However, there is
no doubt that many are attempts to relieve symptoms but likely do not address the true etiology of the disease.

Take a look at this study.

Acta Otolaryngol. 1994 Nov;114(6):657-62.
Radiologic assessment of diseased mucosa of the maxillary sinus after functional endoscopic sinus surgery.
Min YG, Lee JW, Shin JS.
Department of Otorhinolaryngology, Seoul National University College of Medicine, Korea.
We attempted to evaluate postoperative mucosal changes and symptomatic improvement in 99 patients who underwent functional endoscopic sinus surgery
from September 1991 through August 1992. The patients were divided into 2-, 4-, 6-, and 12-month postoperative groups. Thickness of the maxillary
sinus mucosa measured at the midpoint of the lateral sinus wall on a follow-up ostiomeatal unit computed tomogram (OMU CT) was compared with that of
preoperative OMU CT. Postoperative endoscopic findings of the maxillary sinus and changes in presenting symptoms such as rhinorrhea, nasal obstruction,
facial pain, headache, anosmia, epiphora, and referred otalgia were analyzed. Improvement in the diseased mucosa of the maxillary sinus, as evaluated on
OMU CT, was observed in 69.7% of the patients, and such mucosal changes did not differ significantly among 2-, 4-, 6-, and 12-month follow-up groups.
However, apparent mucosal changes exceeding marginal improvement was observed in 32.3% of the patients. The overall symptomatic improvement rate was
57.9% and improvement in endoscopic findings was observed in 46.3% of the patients. Although there was some discrepancy between radiologic and symptomatic
improvement rates, symptomatic improvement was significantly related with radiologic improvement. It is suggested that removal of obstructive lesion in the
ostiomeatal area might be beneficial in a seemingly early symptomatic improvement, but complete healing of the maxillary sinus mucosa as assessed by
OMU CT might take longer than 12 months.

 ----  How would we judge ourselves with radiographic impovement in only 32.3% of our cases.  Compare these results to the CT mucosal improvement
in my case without the patient having undergone any sinus surgery at all.

For a real chuckle, take a look at the final conclusion.

There is much more to properly performed endodontics than most of us give ourselves credit for - Rod

I'll go along with this, though I don't think sinus problems (especially in some areas of the country like the North East) are necessarily caused
by dental infections in most cases (most being as high as 40% or more). I do believe that there are a lot of previous RCT upper molar teeth that
continue to be a problem for the max sinuses and lead to chronic signs and symptoms in this area.  And CT/Scope treatment is very helpful for these
cases.

I don't know how dentists, especially endodontists, have not been sending patients routinely for a CAT and scope of the sinuses with upper molar
symptoms and, especially in this case, a pretty obvious sinus problem even with the PA (whatever the initial cause).

I've been seeing more and more of these "leading" emails on dental lists about using CAT scans for upper molar endo problems for the last year or
so with the advent of the burgeoning sales forces of the iCat people and other makers of these "portable" CAT scans (NewTom, another).

These machines are nice, and are useful, but we, as dentists, have had access to these machines, these scans and ENT scopes forever.  Why is it
just now becoming the rage?  In our office we've been scanning and especially scoping, patients for 15 years on "hard to read" upper molar
cases.  The scope can be especially revealing and treatment, like removing gran. tissue, can be done on the spot. (And the removal of a lesion can
very well be a critical adjunct and necessary to a successful first or second RCT treatment)  But, the scan itself, at the proper scan center, is
also being read by a radiologist for any other peculiarity that may be found, most Dx out of the realm of dental diagnosis.

And at the scan center, the patients' medical insurance in most cases covers the full scan, not the case in the dental office proper.

Hard to justify the price of $175-200K for an Endo scanner (or whatever other dental pathology cases you can dream up using these machines for!)
The percentage of usage is so small in dentistry as to be well taken care of at the scan center down the street.

Of course, there are dentists out there that feel a negative ROI on anything dental, is well worth the costs!!!!!!!!!! In this case, not even
patient care is improved so I'd vote not ready for prime time for these machines for general dentistry and it's even a stretch for surgeons since
they usually have quick and easy access to machines now.

But, at least there are sales people out there showing dentists how to treat these cases.  At least that's a positive (oh, and the profitability
of the scanner company is another positive, too!) - Regards,  Kevin Smith

With all due respect, they have not been readily available until recently. Cone beam tomography was relatively unknown 5 years ago.  Even today, in the
u.s. we have about 700 total installations in a country with 300 million. Medical ct has been available for some time, with a major increase in
radiation exposure to the patient and a major increase in cost of scan, not to mention inconvenience to the patient (300.00 vs. 8-900 in my area)

5 new machines are scheduled to come on the market this year, possibly the same next year.  There are currently 5 available (if we count the sirona
being available the first of the year being available now).

I insist the tipping point for this technology will be 100k.  Once it gets to that level, I think many practitioners will embrace the multitude of
benefits of 3d imaging - Gary

Kevin, To clarify, the vast majority of rhinosinusitis cases are acute with the leading cause being ostial blockage from mucosal edema in response to an
allergen.  These clearly have nothing to do with dental pathosis, although they can cause a patient to experience "molar tooth pain" due to pressure
and anatomic proximity or heterotropic convergence from the sensitive ostium.

The 40+ percentage is not of "all sinusitis", but is rather a percentage of only the chronic, non-resolving cases that have not responded to
antibiotic, adjunctive or surgical therapies.

I share your appreciation of CT imaging in diagnosis, but I should clarify that under no circumstances do I use them to "diagnose" a sinusitis,
rather to aid in my dental diagnosis.  I leave the sinus diagnosis to the ENT's.

I just hope they reciprocate by leaving the dental diagnosis to me. :-))) - Rod

I follow that now.  But I've had a few cases whereby the CAT/scope procedure by the ENT cleared out the soft tissue lesion and then was
followed by successful (so far) RCT.  I've always felt that some RCT upper molars that do not fully resolve (transient symptoms, etc.) may very well
be solved with a "scope and scrape" procedure (as my ENT calls it).

It's difficult in the NE simply because most people have such thick membranes from the constant irritation from either allergies or poor air
quality. Those thick membranes sure make sinus lifts easy, though!!!!!!! - Kevin Smith

Yes, I have heard of cases like that too, although I haven't actually seen any personally.  Cases where the secondary sinus infection does not entirely
resolve and the mucosal tissue is still hypertrophic requiring surgical follow-up by the ENT.  Perhaps akin to the need for apical curettage in some
endodontic cases in spite of our best non-surgical efforts. - Rod

Kevin, To clarify, the vast majority of rhinosinusitis cases are acute with the leading cause being ostial blockage from mucosal edema in response to an
allergen.  These clearly have nothing to do with dental pathosis, although they can cause a patient to experience "molar tooth pain" due to pressure
and anatomic proximity or heterotropic convergence from the sensitive ostium.

The 40+ percentage is not of "all sinusitis", but is rather a percentage of only the chronic, non-resolving cases that have not responded to antibiotic,
adjunctive or surgical therapies.

I share your appreciation of CT imaging in diagnosis, but I should clarify that under no circumstances do I use them to "diagnose" a sinusitis, rather
to aid in my dental diagnosis.  I leave the sinus diagnosis to the ENT's.  I just hope they reciprocate by leaving the dental diagnosis to me. :-))) - Rod

On 10/30/06 5:27 AM, "Kevin Smith" wrote:

But, for the case that started this thread, how does the patient not  get
superior care at the scan center down the street and the scope and
diagnostics/treatment from a radiologist and ENT?  And everything is
covered by medical insurance so out of pocket for most patients is nill.

If you think that patients won't revolt over $300 scans they could get for
free down the street you're fooling yourself.  It is also a bit of a
disservice to the patient by not utilizing their medical coverage in a
scan center environment.  For most offices, this is a big deal simply
because for most patients it's a big deal.

OK, less radiation on an occasional problem, I'll give you that one.  But,
in the overall scheme of things, is that significant to you?  Is that the
over-riding factor for the purchase of this machine for the GP or the
Endodontist? You'd still need to get the scan and the patient to the ENT
for further evaluation.

Kevin, You’ve mentioned this a few times.  Allow me to comment. I personally do not call for a CT scan for anyone’s diagnosis but my own.  We are the clinicians
with the education and experience to diagnose or rule out conditions with an odontogenic etiology.  If the patient or another doctor would like to see the scan for their
own diagnostic purposes in their area of expertise, the scan is certainly is available to them.  I may even request their input on occasion and I have several ENT’s I work with.
hey also call on me.

As I said in an earlier reply to you, “I leave the sinus diagnosis to the ENT’s, and I would hope they reciprocate by leaving the dental diagnosis to me”.

I assure you from many past experiences that the patient does not automatically get superior care at the scan center down the street nor from diagnostics/treatment from a
radiologist and just any ENT, especially if the etiology of the sinus infection is dental.

Prior to the convenience and significantly reduced cost (and reduced rads) of digital CT’s like the iCat, I would send my difficult diagnostic cases for a full coronal
CT scan which ran about $1000 per scan.  I didn’t do too many of these due to the cost.  Even a limited coronal CT (about 16-18  3mm cuts), which is pretty worthless
diagnostically compared to an iCat still costs about $250.

Here is a view of one from back in 2003.  I didn’t order this one, but the patient paid for the scan and another couple hundred bucks for a radiologist’s diagnosis who said her
CT was clear.  He found “no abnormalities”.  I could scan and post his report.

I requested to see the CT prior to my endodontic dx.

Take a look at this coronal cut through the upper left second bicuspid.
See anything “abnormal”?
Dx: necrotic pulp tooth #13 with CAP and secondary mucositis in the left maxillary antrum.
Here are the radiographs:


This patient’s “condition” was diagnosed and successfully treated, despite the expertise and imaging at the scan center down the street.  Her chronic symptoms have resolved.
I’ve got some other interesting examples of the “superior care” of some ENT’s if you’d care to see it - Rod 

Thank you rod.  At last a voice of reason.  As far as fees, your scans are a relative bargain.  In our area 300-350 is more the going rate, which is still a bargain both
dollar wise, convenience wise, and total body exposure wise over medical grade ct - Gary

Gary, I would add that they are also much better “diagnostics wise”, because you can essentially move through the bone (and sinus) visually in coronal, sagittal, and axial
dimensions with virtually “infinite cuts”, as opposed to being held to only one dimension with limited cuts on the medical grade scans.  Especially the limited CT’s –
with those 3 to 4 mm sections, looking for periapical pathology, etc.  is extremely hit and miss.

We’ve got another OS in our area with an iCat who I spoke with yesterday.  They charge $290 for a scan - Rod 

Hey Rod, Great application of a great technology.  I believe there is a tremendous application for CT scans in endodontics and have observed many interesting
endodontic situations that were also not visible with conventional x-rays through the use of i-CAT CBCT.

Disclaimer: I have a mobile i-CAT and sell i-CAT imaging services to other dentists.  Regardless, I had really not considered that there would be an important
application in endodontics and boy was I wrong.  You cant underestimate the value of the third dimension in any application.

Question:  did you get just these views form the imaging center or did you get the volume and then slice out the views you wanted?
Great case and images. - Arturo

Arturo, Thanks. Originally, I would ask for specific slices and views of what I wanted, but about 9 months ago I received the beta program that allows
me to get the volume on disc and then slice out any image I choose.  This is incredibly valuable technology and I believe has a place in endodontics, particularly
in the maxillary posterior region for MSDO cases and where radiographs can be difficult to read, as well as locating the IA nerve and mental foramen prior to
mandibular surgery. I certainly don’t have the number of case applications to warrant purchasing one for my office, but I never hesitate to send a patient to my
OS buddy who has one if it will aid in my diagnosis - Rod

The use of cone beam tomography in endo was presented at the ada in vegas in the cone beam course i attended by the director of the radiology group at usc - Arturo

John, I just emailed Rod, it's a great work up, but with the mesial restorative under the margins...I would have just done endodontics, perhaps a test cavity
(but I've had those lie) - Joey D

Very, very interesting workup Rod. But you forgot something.  Look again.   Take your endodontist glasses off.  :-)))
How much are the iCats in your area? Can you post larger images for us to look at? This is a great diagnostic case.
I'm gonna use it in my next lecture.  Thanks. - John

Hey John, My OS charges $250 for each iCat scan.  Then he sends it to me on a disc which I keep.  The patient gets a disc too if they want.
That’s not a bad idea – cleaning up the cement.  I tend to draw a very tight line between my work and the restorative guy’s stuff, but I’ve seen a need with some of
my referrals to take a more proactive role in certain restorative aspects of my cases.  I appreciate your comments - Rod

Rod, $250.  Not bad.  At $250 I might send.  At $900, umm....How do you bill for it?
Is it covered by their dental?  Medical?  Both? And if so, what procedure codes to you use? - John A Khademy

John, I don’t bill for it, because I didn’t do it.  The OS bills the patient or their insurance for it.  I really don’t know if the pts medical covers it.
I suppose if I ever bought an iCat I would have to find out what codes to use.

Its the same thing with a pano.  I don’t have a machine, but I send the patient for one prior to any mandibular surgery.  If their GP doesn’t have a machine,
I’d send them to my OS.  The patient (or their insurance) is billed by the OS.  I’m not involved in the transaction even though I requested the image - Rod

I’m not sure what coverages are in our area.  Patients have covered the costs themselves.  If I’m quoting 20-40 k for an implant recon,
300 bucks is not a deal breaker - Gary

Icat goes for about 180k, But price is supposed to increase now that schein is marketing, and not to be forgotten is the little matter of 5-7k annual maintenance fee.
Sirona is supposed to be  about 190k, Illuma about the same.  Morita and Newtom are over 200k, and Hitachi over 300k - Gary

Hi John, I always love your insight buddy.

Let me guess.  The big chunk of cement on the mesial #15 margin.  I know – I talked to the referring doc about it and he removed it right after my RCT.  You’ll see
it is gone on the follow up scan.  Anything else???

I believe the iCats run about 150K base, but you can get to over 200K pretty quick with a few bells and whistles.  I haven’t officially priced them out – just talked
to my OS buddy about it.

I’ll send you some larger images to your personal email to not overload too many mailboxes.  Crop and draw all you want bud - Rod

Rod, I don't think it's just cement on the mesial under the bridge... In any case, the extent of it led me to think "That's probably it" - Jeoy D
I think it is just the cement - Guy

The i-CAT is ~$170,000.  I think it is a good purchase for a group of like minded dentistrs - Arturo