From: Fred Barnett
To: ROOTS
Sent: Tuesday, November 24, 2009 2:14 AM
Subject: [roots] cbct du jour

Tooth #30: PA and CBCT....enlightening, no??? - Fred




Did it probe?  - Terry

Scary..... Amir

Though not to the extent that the cone beam shows, that lesion is easily visible
on a conventional radiograph.  The amazing ones are the ones which do not show on
the radiographs.  The radiologists are showing off their new machine at our
hospital by sending me all the lesions I’ve missed. I told them to keep it up - Guy

where's the lesion fred?  that big hole the tooth is sitting in obscures it?
not sure you really needed a cbct for that one, but it does give you the
3d perspective - Gary

LOL.....the scan shows how far coronally that lesion extends - Fred

actually, i take back my stupid statement.  you need a baseline scan so we can
see what real healing looks like in 3 dimensions a few months hence - gary

I bet the bite wing and straight angle PA show a large furcation blow out as well.
- Terry

onthis beautifuly angled xray  on 46 mesial root there is already a less
radioopaque region visible suggesting a bone  loss - gurpreet

hi fred-  question for me -  is it necessary to do cbct?  in this
case- which pocket depth you got? wouldnt it be enlightend enough to
me. do i need a cbct then? - Dennhardt H

There is a big difference between having to do cbct and having it in house
as fred does to document everything they do.  Remember we all are looking
with 20/20 hindsight.  How do we know the lesion is big as a house?  Because
fred showed us a scan in the proper plane.  When you have a cbct in house,
you owe it to yourself and to your patients to scan everything in site.
"endo teeth are like a box of chocolates.  You never know what your gonna
get."  Hmm, maybe I should become a writer - Gary

Gary, There is a pragmatic issue here. Although we now have a CBCT in house it
still doesn't seem appropriate to scan every patient who walks through
the door.

We may have 20/20 hindsight but there are those clinicians with no
foresight, some with 10/10 foresight and maybe a few with 15/15
foresight.  CBCT info is still a bit blurry and not the resolution of a
high quality digital PA which still provides a superb tool for diagnosis
if taken with skill and an understanding of angle adjustments, even
though it's just 2-D.  The additional 3-D info of a CBCT is extremely
helpful in predetermination of complexities for retreatments,
resorptions, implant planning, and odd things like sinus path.  CBCT's
still rarely change treatment plans but do alert the clinician ahead of
time to existing complexities that would otherwise be a surprise
challenge. In this age of medical testing and over utilization of
services to cover one's legal butt, one should always consider risk
benefit when ordering CBCT's.  Economics are a factor and it is not
unethical to balance financial pragmatism into the risk/benefit
equation.  I do not consider my CBCT machine to be a "cash cow" but
rather an opportunity to truly serve my patients better when they need
it; which is frequent, but not routine.  Treatment charges shouldn't be
ramped up just to universally apply a CBCT scan thoughtlessly to each
case.  It is a complicated consideration for utilization and how to
charge for scans is a dilemma:

1. How do you charge the patients to cover the added overhead expense of
installing a CBCT (assuming you don't pimp it for a product company and
get one for free)?
2. Do you act like a socialist and raise your root canal fee burdening
all your patients analogous to increased taxes so that the minority that
need it can have it for no "additional" CBCT fee?
3. Do you start frothing at the mouth and greedily "sell" CBCT scans as
a consultation "add-on" to everyone who walks through the door
explaining that it is an absolute necessity so that nothing is missed in
treating their case?
4. Do you look at each case uniquely as one requiring specific
diagnostic information that may, may not realistically require 3-D CBCT
information to determine prognosis, identify disease entities, then
communicate the relative treatment value of this information to the
patient along with the fee and let them determine whether to purchase
the additional diagnostic service?

I've been ordering CT scans for several years and only now have it as an
"in-house convenience" making it more accessible and affordable. The
utilization definitely goes up when you have it in-house.  A situation
like Fred's where he's using it for educational purposes makes the
utilization issue simpler and it makes sense to use it on every case so
the students can get maximum learning benefits.

Should all patients be required to subsidize CBCT exams including those
ones who don't need it just to satisfy the malaise and convenience of a
lazy thinking clinician who simply wishes to practice without taking the
time to discriminate the unique reasonable exam needs of a presenting
case?

I'll forward the last two scans I took for patients and the reasons they
were ordered.  They seem to demonstrate the interesting importance of a
CBCT unique to these specific cases.

Endo teeth may be like a box of chocolates, but to Forrest Gump running
fast in the wrong direction, even a CBCT won't help redirect unskilled
ignorance; it may even entice a "clownician" to "search and destroy".
:):):) - Terry

Terry, What exactly does more affordable mean? The money thing is really fudgable.
Typically it is those who can afford it, pay for those who can not.  So many
variables come into play...ie. how much staff do i need vs. want. What do I want
my facility to look like. How many operatories? Do I need all the bells and
whistles with each of my scopes? How many days should I be working? How many
days do I want off? Do I want to teach part time/ full time? Volunteer or get paid?
Scope with inclinable binoculars? reticle? beam splitter? three chip video?
assistant scope? SLR?

Oh yeah, how about that CBCT? Do we go ahead and purchase it, or now there is a
mobile cbct that will go to the patients home!!??!! Do I NEED it? or
can I "farm " it out?

Liabilities? So many choices? I LOVE IT!!!!
I know of two different endo practices in Manhattan who have CBCTs. One has each
patient take the scan for $100.00 U.S. (a reduced price). the other has  a group
practice, and probably has 35% take an exam for full price ($250.00 U.S.).
I find it interesting.
Like all other aspects of our practices, we have the ability to choose!!
What I am seeing more and more, especially here, is all of the applications where
Cone Beam can be helpful in treatment decisions. I do believe there is a place
for it in my practice. However, I can't help but think there would be a desire
to just "see what I could see" by taking the scan a few more times than needed.

Big question for me is : we see what appears to be peri apical bone loss in a scan
.......asymptomatic....do we treat ? or watch? what are the criteria? are they
the same as with peri apicals?

I have alot of questions......any answers? - Mike

hi terry:  ROFL-  a socialist would argue:   if you have more
informations its easier for you to treat- so your fee has to be decrease-
dont lough-  we had some letters with exact this argumentation... Dennhardt H

I'm not laughing we have a president making that argument. In reality
if you have more information you have to spend more time analyzing it to
assimilate the treatment planning algorithm and communicate it.  I
actually have a "C" referring dentist who tells his patients to go to me
to figure out what their problem is, but after I find out what it is, to
come back to their office for treatment at a discounted fee. Of course
I'm not supposed to know about that secret arrangement.  The only way I
know about it is that several of the patients asked me about this guy
after he screwed up their treatment wondering if that was unethical. I
usually say, "Not unethical, just stupid". :):):)

We clearly don't get paid enough for our brains, only our hands.  Lose a
hand and you can't make a living in dentistry; lose your brain and your
sill fine as far as the government is concerned.   -  Terry

thats true-  welcome to the club - Dennhardt H