This regular column is compiled by JCO Contributing Editor John W. Graham, DDS, MD. Selected participants are asked for brief replies to a series of questions on a single topic. Your suggestions for future Hot Seat topics or participants are welcome.
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- THE HOT SEAT Clear Aligners February 2015
- THE HOT SEAT Accelerated Orthodontics April 2016
- THE HOT SEAT Temporary Anchorage Devices February 2014
Do you use a CBCT machine as your primary imaging modality?
Sean K. Carlson, DMD, MS
Mill Valley, CA
Yes, we use CBCT on every patient.
Stuart Frost, DDS
Mesa, AZ
Yes.
Duane Grummons, DDS, MSD
Spokane, WA
Limited-field-of-view miniscans are prescribed for 40% of my patients, larger field-of-view scans for 5%.
Ed Lin, DDS, MS
Green Bay, WI
Absolutely! Especially with low-dose CBCT.
James Mah, DDS, MS, DMS
Las Vegas, NV
Yes, it is the most comprehensive imaging modality available in orthodontics, and it has the best diagnostic specificity and sensitivity.
Aaron Molen, DDS, MS
Auburn, WA
Not yet. We use it to supplement our 2D radiographs as needed, but as we replace old equipment we will move in
that direction.
Juan-Carlos Quintero, DMD, MS
Miami, FL
It is my only imaging modality.
J. Martin Palomo, DDS, MSD
Cleveland, OH
Yes. One of my CBCT machines also offers true panoramic and ceph options. The clinical examination dictates which radiographic modality would best answer my questions.
Jeff Kozlowski, DDS
New London, CT
Yes, I use the i-CAT FLX as the only imaging modality in my main office.
Seong-Hun (Sunny) Kim, DMD, MSD, PhD
Seoul, South Korea
Half and half. I use it for initial and final records, and the rest are taken with 2D x-rays.
Commentary by Dr. Graham: No reason not to.
Do you prefer the standing or seated type of CBCT machine?
Sean K. Carlson, DMD, MS
Mill Valley, CA
I prefer a sitting model. I think it is easier to get fidgety kids to sit still as opposed to stand still.
Stuart Frost, DDS
Mesa, AZ
I have owned both and I prefer sitting, because there is less patient head movement.
Duane Grummons, DDS, MSD
Spokane, WA
I prefer sitting models for comfort and head stability, reclined models for sleep- or breathing-disordered patients.
Ed Lin, DDS, MS
Green Bay, WI
Sitting types provide better stability for the patient to minimize any movement.
James Mah, DDS, MS, DMS
Las Vegas, NV
No preference. Staff training is essential to minimize motion artifacts.
Aaron Molen, DDS, MS
Auburn, WA
Seated, absolutely. CBCT is very sensitive to motion artifacts, and sitting reduces the amount of movement by one-third vs. standing.
Juan-Carlos Quintero, DMD, MS
Miami, FL
Sitting, due to reduced patient motion during acquisition.
J. Martin Palomo, DDS, MSD
Cleveland, OH
I have both, and even though standing offers easier wheelchair access, I still prefer my sitting model because I find that patients are better able to keep still.
Jeff Kozlowski, DDS
New London, CT
I prefer sitting models, because they help reduce patient movement.
Seong-Hun (Sunny) Kim, DMD, MSD, PhD
Seoul, South Korea
Sitting; it’s more comfortable for patients. The standing model is smaller and can be combined with panoramic radiographs, but it has a negative effect on image quality due to the shorter distance between tube and detector.
Commentary by Dr. Graham: Sit down!
Have you encountered resistance to using CBCT?
Sean K. Carlson, DMD, MS
Mill Valley, CA
Very little. I created some podcasts to help answer questions about dosimetry and educate patients (http://youtu.be/
jTi_RlKwAng).
Stuart Frost, DDS
Mesa, AZ
Not only have I not had resistance, but I have had parents and patients thank me for using the latest imaging technology.
Duane Grummons, DDS, MSD
Spokane, WA
Sometimes, regarding radiation exposure. We educate patients about ambient radiation (e.g., air travel, sunshine) and the low doses of CBCT vs. dental x-rays.
Ed Lin, DDS, MS
Green Bay, WI
No. We have educated our patients on the risks and the benefits.
James Mah, DDS, MS, DMS
Las Vegas, NV
Yes, mostly from individuals or professional groups that do not understand radiation dosimetry and risk-benefit analyses. I have never had a patient decline this diagnostic test.
Aaron Molen, DDS, MS
Auburn, WA
Never from any patients or parents; just once from a local pediatric dentist.
Juan-Carlos Quintero, DMD, MS
Miami, FL
Very seldom, once the risks and benefits are explained.
J. Martin Palomo, DDS, MSD
Cleveland, OH
Only from other dentists; never by a patient.
Jeff Kozlowski, DDS
New London, CT
Only from the uneducated.
Seong-Hun (Sunny) Kim, DMD, MSD, PhD
Seoul, South Korea
I occasionally get questions from patients about the risk of radiation dosage.
Commentary by Dr. Graham: As Dr. K. implies, resistance is a teaching moment.
How often do you have your CBCT scans read by oral and maxillofacial radiologists?
Sean K. Carlson, DMD, MS
Mill Valley, CA
Rarely—only if there is something on the image I do not recognize. CBCT scans are much easier to read than two-dimensional panos and cephs.
Stuart Frost, DDS
Mesa, AZ
Fewer than 10% are sent out to be read.
Duane Grummons, DDS, MSD
Spokane, WA
90% of my full-volume scans, 3% of the mini-scans. The radiology report is a useful tutorial.
Ed Lin, DDS, MS
Green Bay, WI
It is a patient option on our informed-consent form, used by about 33%.
James Mah, DDS, MS, DMS
Las Vegas, NV
I review and report every case but have access to oral and maxillofacial radiologists and oral pathologists as needed.
Aaron Molen, DDS, MS
Auburn, WA
Whenever I don’t recognize something, which is about 5% of the time.
Juan-Carlos Quintero, DMD, MS
Miami, FL
100% of my pretreatment scans at first; now only about 25% of my initial scans.
J. Martin Palomo, DDS, MSD
Cleveland, OH
Regularly.
Jeff Kozlowski, DDS
New London, CT
Never.
Seong-Hun (Sunny) Kim, DMD, MSD, PhD
Seoul, South Korea
All the time. The radiologist takes my CBCT scans.
Commentary by Dr. Graham: Comfort level is key. For me, three times in six years.
What are you using CBCT scans for other than diagnosis?
Sean K. Carlson, DMD, MS
Mill Valley, CA
Progress scans and third-molar review, which usually involves an 8cm x 8cm scan using QuickScan+ technology—only 6.7 microsieverts of exposure!
Stuart Frost, DDS
Mesa, AZ
Airway evaluations, TMJ, digital models, and treatment planning for variable-torque bracket selection.
Duane Grummons, DDS, MSD
Spokane, WA
Airway co-management, Grummons Frontal Asymmetry analysis, and pediatric facial orthopedics.
Ed Lin, DDS, MS
Green Bay, WI
Creating SureSmile wires.
James Mah, DDS, MS, DMS
Las Vegas, NV
Anatamodels to replace stone models, treatment monitoring (progress records), 3D hard and soft-tissue simulations, and outcome assessments.
Aaron Molen, DDS, MS
Auburn, WA
Nothing else yet, but other uses are inevitable.
Juan-Carlos Quintero, DMD, MS
Miami, FL
Virtual treatment planning through dynamic modeling and customized appliance fabrication.
J. Martin Palomo, DDS, MSD
Cleveland, OH
I have done treatment simulations, created digital casts, and fabricated appliances.
Jeff Kozlowski, DDS
New London, CT
Communication with patients and parents, as well as communication and marketing with other dental professionals.
Seong-Hun (Sunny) Kim, DMD, MSD, PhD
Seoul, South Korea
Fabrication of CAD/CAM appliances such as Invisalign, customized fixed appliances, and digital indirect bonding.
Commentary by Dr. Graham: The sky's the limit.
Does CBCT make you a better clinician?
Sean K. Carlson, DMD, MS
Mill Valley, CA
Yes, without question. My practice is light years ahead of where it was before I got my first machine in 2008. I always tell newbies, “Just wait ’til you see what you don’t know you’ve been missing!”
Stuart Frost, DDS
Mesa, AZ
Yes! I have more confidence in diagnosis and treatment planning, which leads to better finishes.
Duane Grummons, DDS, MSD
Spokane, WA
Yes, 2D vs. 3D is like lanterns vs. electricity. I don’t trust 2D panos due to distortion and magnification issues; 3D offers many diagnostic advantages and treatment efficiencies, as long as you know the obstacles and risks.
Ed Lin, DDS, MS
Green Bay, WI
Better diagnostics = better treatment planning = better results.
James Mah, DDS, MS, DMS
Las Vegas, NV
I can’t work without it.
Aaron Molen, DDS, MS
Auburn, WA
Without a doubt.
Juan-Carlos Quintero, DMD, MS
Miami, FL
Yes, I now realize the many clinical mistakes I used to make without it.
J. Martin Palomo, DDS, MSD
Cleveland, OH
Yes, in diagnosis, treatment planning, and patient communication. The patient understands a CBCT more easily than a lateral ceph.
Jeff Kozlowski, DDS
New London, CT
Absolutely! Once doctors start treatment planning from CBCT, they will wonder how they ever worked without it!
Seong-Hun (Sunny) Kim, DMD, MSD, PhD
Seoul, South Korea
Sure! Analyzing the alveolar bone thickness and root length before starting treatment makes it more comprehensible to patients, and also helps prevent any lawsuits.
Commentary by Dr. Graham: Indubitably!
What are the hurdles that prevent more clinicians from using this technology?
Sean K. Carlson, DMD, MS
Mill Valley, CA
Three myths: dose too high (it can actually be lower), cost too high (it’s a manageable investment that is in the patient’s best interest), learning curve too steep (educational resources and research are increasingly available).
Stuart Frost, DDS
Mesa, AZ
Fear of the unknown and price of the equipment.
Duane Grummons, DDS, MSD
Spokane, WA
Costs, the effort needed to achieve 3D proficiency, not grasping why 3D is better, and fear of missing pathoses.
Ed Lin, DDS, MS
Green Bay, WI
Learning something new takes time, training, and implementation of systems.
James Mah, DDS, MS, DMS
Las Vegas, NV
Education—knowing how to visualize, interpret, and apply the wealth of information that is provided.
Aaron Molen, DDS, MS
Auburn, WA
It used to be radiation misinformation, but now I believe it’s the cost of the equipment.
Juan-Carlos Quintero, DMD, MS
Miami, FL
Cost, misinformation about dosimetry, and the intimidation factor of the technology.
J. Martin Palomo, DDS, MSD
Cleveland, OH
The cost and the fear of buying something that could soon be obsolete.
Jeff Kozlowski, DDS
New London, CT
Cost, cost, cost.
Seong-Hun (Sunny) Kim, DMD, MSD, PhD
Seoul, South Korea
Radiation dosage! If this obstacle can be overcome, it would revolutionize our diagnostic methods.
Commentary by Dr. Graham: Given low-dose radiation reality, cost is the only excuse.
Will CBCT become the standard of care in orthodontics?
Sean K. Carlson, DMD, MS
Mill Valley, CA
Yes, without question. The advantages far exceed the disadvantages, especially now that CBCT images can be acquired with less radiation than with 2D images.
Stuart Frost, DDS
Mesa, AZ
I think it should be, though I don’t see it happening any time soon.
Duane Grummons, DDS, MSD
Spokane, WA
Differentially, yes, for maxillofacial surgery, implants, craniofacial disorders, facial trauma, jaw asymmetry, TMJ intracapsular pathosis, airway, and sleep disorders. Time will tell about the rest.
Ed Lin, DDS, MS
Green Bay, WI
After nine years of experience, I feel it already is.
James Mah, DDS, MS, DMS
Las Vegas, NV
As more clinicians adopt the technology and teaching programs include CBCT in their curricula, it will become a standard, similar to what we see in dental implantology.
Aaron Molen, DDS, MS
Auburn, WA
Yes, progress is inevitable.
Juan-Carlos Quintero, DMD, MS
Miami, FL
Inevitably, now that ultra-lowdose CBCT outperforms higher-dose panos and cephs.
J. Martin Palomo, DDS, MSD
Cleveland, OH
Yes, we clearly benefit from 3D imaging. Unless magnetic resonance imaging or ultrasound make significant advances, I would expect
utilization in every office.
Jeff Kozlowski, DDS
New London, CT
Isn’t it already? How can more information for less radiation than standard 2D images be anything less than standard of care?
Seong-Hun (Sunny) Kim, DMD, MSD, PhD
Seoul, South Korea
Possibly, but there’s a long way to go. Progress in hardware and imaging programs could make it happen.
Commentary by Dr. Graham: Nobody thought laparoscopic surgery would ever become the standard of care.
How do you think we will be using CBCT scans in the future?
Sean K. Carlson, DMD, MS
Mill Valley, CA
CBCT will likely be used to enhance computer-aided orthodontic treatment, probably through custom bracket and wire design and custom mechanics.
Stuart Frost, DDS
Mesa, AZ
Cone-beam scans, intraoral scans, and clinical photography will integrate seamlessly for better diagnosis and treatment planning, making excellent digitally based orthodontics a reality.
Duane Grummons, DDS, MSD
Spokane, WA
We will be able to produce an anatomically correct 3D patient with true jaws, dentition, and soft tissues superimposed on a stereoscopic capture of functional jaw motions and smile dynamics. All this with interactive communications—it just keeps getting better!
Ed Lin, DDS, MS
Green Bay, WI
CBCT will only get better in terms of diagnosis, treatment planning, and treatment!
James Mah, DDS, MS, DMS
Las Vegas, NV
CBCT will become the platform for virtual dental patients, in which other “tests” such as intraoral scanning, facial imaging, jaw motion capture, occlusal forces, and bite registration are integrated. This will lead the way to digital design and manufacturing of custom appliances.
Aaron Molen, DDS, MS
Auburn, WA
For appliance fabrication and indirect bonding.
Juan-Carlos Quintero, DMD, MS
Miami, FL
CBCT will replace 2D imaging, providing a single, all-inclusive diagnostic record from which customized appliances are manufactured.
J. Martin Palomo, DDS, MSD
Cleveland, OH
Versatility will be key, unlike the one-size-fits-all solution that the ceph offers in 2D orthodontics. Different sizes, settings, and uses will become available throughout treatment.
Jeff Kozlowski, DDS
New London, CT
For world peace!
Seong-Hun (Sunny) Kim, DMD, MSD, PhD
Seoul, South Korea
High-resolution CBCT will minimize scattering, so that x-rays are efficiently converted into electrical signals and ultimately much sharper images. This will reduce the number of scans needed for diagnostic and treatment and thus reduce radiation dosage.
Commentary by Dr. Graham: Well beyond anything we can imagine today.