Dr. Howard Farran and Dr. Shawneen Gonzalez talk about
oral radiology, CBCT, CAT scans and more!
Listen to the Show on iTunes
Click here to listen on iTunes
Stream the Podcast Here:
Howard Speaks Audio Podcast #26 with Shawneen Gonzalez
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Watch the Video Podcast Here:
Howard Speaks Video Podcast #26 with Shawneen Gonzalez
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Links and References from the Show
- Dr. Gonzalez's educational website for oral radiology: DrGsToothPix.com
- The American Academy of Oral and Maxillofacial Radiology
(AAOMR): AAOMR.org
- Joint AAE/AAOMR
paper on CBCT in Endodontics
- Upload your dicom CBCT files to be interpreted by Dr. Gonzalez at Legacy3d.com
- HIPPA compliant file transfer (like Dropbox) HighTail.com
- ADA radiograph recommendations
- Radiation calculators: EPA, xrayrisk.com, Nuclear Regulatory Commission
In This Show We Cover:
- Oral and Maxillofacial Radiology as the
newest ADA recognized specialty
- Where does the name Cone Beam Computed
Tomography (CBCT) come from and why is it different than medical a
medical CT?
- What settings should I use on my
CBCT for Endo diagnosis?
- Should I buy a
CBCT?
- Who invented CBCT?
- To thyroid-collar or not to thyroid-collar with CBCT?
- How to talk to patients who don't want X-rays
- Turn a desire to avoid X-rays into oral hygiene motivation
- What is a Dicom file and why should I care?
About Dr. Shawneen Gonzalez:
Dr. Gonzalez
is the Director of the Oral and Maxillofacial Radiology Clinic, Assistant
Professor and Radiation Safety Officer at Oregon Health & Sciences
University School of Dentistry, Portland, Oregon. She received her dental
degree from the University of Washington School of Dentistry, Seattle,
Washington and her oral and maxillofacial radiology certificate and M.S. in
Stomatology from the University of Iowa College of Dentistry, Iowa City,
Iowa. She is a Diplomate of the American Board of Oral and Maxillofacial
Radiology.
She is the course director of several clinical and didactic oral radiology
courses for residents and dental students and the creator of an
informational oral radiology website (http://drgstoothpix.com) where she
educates other dental professionals around the world. Her research
interests include education methods of oral and maxillofacial radiology and
cone beam CT uses. She is currently using twitter in the classroom as well
as educating others with her ‘Radiograph of the day’. Her
twitter account (@DrGstoothpix) has approximately 1,700 followers with 60%
of those followers from outside the United States. She is a contributor to
DrBicuspid.com and ThenextDDS.com providing cases and sample
radiographs.
She is a member of the American Association of Oral and Maxillofacial
Radiology, Radiological Society of North American, American Dental
Education Association and the American Dental Association. She serves on
the pre-doctoral and post-doctoral committees for the American Association
of Oral and Maxillofacial Radiology.
Podcast Transcription (Download
Here):
Howard Farran: It is, uh, a huge honor to be with one
member, uh, a star member of our brand new profession, uh, specialty, the
ninth specialty which was the, um, Max oral, maxillofacial radiology. So,
when I got out of school, in ’87, and uh, there were only eight, and
I, I never saw this coming. I have to tell you, at 52 years old, I, um, I
remember seeing the first cell phone, a patient walked in and there was
this brick with a cord, a brief case, and I said, that’s, you know,
why don’t you just use a phone. I didn’t see the cell phone
coming. Refresh me, you’re at Creighton, I know you, uh practiced in
Lincoln, Nebraska, for a while. Uh, refresh me, you were at Creighton in
1980 in Omaha, Nebraska, friend of mine showed me a handy personal
computer, and demoed the whole thing to me and I said, That’s got to
be the stupidest idea ever. And I have to tell you, I didn’t see oral
or maxillofacial radiology coming, so Shawneen, I’m a big fan of
yours on social media, I follow you on Twitter, I love everything you do
with teaching, uh, radiology. I just think you’re a, you’re a
dynamo. I really do.
Shawneen Gonzalez: Well, thank you.
Howard Farran: But, let’s open up to all the old guys – why
is this a new specialty? And what made you become a new specialty member of
this brand new specialty?
Shawneen Gonzalez: Well, I was really fortunate in a sense that when I went
to dental school, I actually had three radiologists teach me. Most dental
schools don’t have three radiologists, and one of the guys actually,
Dr. Lars Hollander, he just turned 80 and he’s still teaching, which
is insane in my opinion, but you know, he’s still sharp as a whip so
that, I mean, that’s awesome for him there. When I was in dental
school, I just did a little research that involved me being a
radiology clinic. I just had a really fun time in there
where I would ask a lot of questions like, you know, what’s this,
what’s this, what’s this, and after about like two weeks or so,
they turned it around on me when I was doing my research, and they started
quizzing me on all the questions, and then my, Dr. Hollander, he’s
got some crazy, crazy stories, like I remember one time he comes, he looks
at these radiographs, hasn’t even seen the patient, hasn’t seen
their name, doesn’t know anything about them, and he’s like, he
looks at them, does a little bit with a student, and then he goes off, he
says, I want to talk to your patient. Goes off to the patient and goes, Do
you have a history of kidney stones? And the patient’s like, Why yes,
I do, and I was just like, I thought it was so cool, like the mystery
aspect of learning about a patient off of just imaging, without actually
having the chance to meet them first. So, it’s like a big mystery to
me. And so after he saw my interest, he’s like, There’s a
specialty for you if you’re interested. Kind of just kept nurturing
it every time there was a weird case in dental school, Hey, why don’t
you come check this out, and so after about a year or so, I was like, I
think I want to go into this and be in the education world where I get to
see a lot of weird, crazy stuff and challenge myself every
day.
Howard Farran: Well, that is, that is a beautiful story. Now,
that’s you, but why did the American Dental
Association, I mean, because they’ve been requested for
a specialty for implantology, which I thought that would have been the next
one, and then out of nowhere comes oral radiology.
Shawneen Gonzalez: Well,
radiology, their, the specialty of oral radiology actually has been around
for quite some time. The academy was officially formed like back in the
‘40s and the ‘50s, and the reason I think that they finally
were pushing more so in the ‘80s and ‘90s to become a specialty
is the rise of 3D imaging. CT imaging was coming on the scene, it was
really picking up in medicine, but people were finally starting to realize
that we can use this in dentistry. And this is before cone beam CT even
came to be. But, they realized that with these advanced imaging, there
really wasn’t anybody who was trained to not only understand how the
imaging works, but also understand how to interpret these images, besides
beyond say the pathologists who understand obviously quite a bit as well
about radiology, but they also have the histology aspect they focus more on
because they have histopathological slides. So, they pushed primarily for
those additional imaging, but also for the teaching aspect for students, to
make sure the new generation of dentists coming out have a really solid
radiology foundation so that they can be ready for the next thing
that’s coming in dentistry.
Howard Farran: It really is the ultimate non-invasive surgery,
isn’t it?
Shawneen Gonzalez: Yes it is, that is true.
Howard Farran: It is truly amazing, and I thought I had the most
incredible training and anatomy and physiology with Dr. Bernard Butterworth
at UKMC. I mean, he was a master, and I saw my first CBCT and I never felt
so humbled in my life. I mean, I didn’t know what
anything was. And I was looking at all that and, and just yesterday, Dr.
Glass and I were both looking, and here I’m 52, he’s 56,
we’re both sharp guys, and we, there was something in there and we
were looking at that, we didn’t have any idea what it was. So tell
me, so how prevalent is CBCTs? And by the way, someone earlier said that
the CBCT really isn’t even the correct name for what we’re
using it in dentistry, that cone beam CT, that like I bought a Carestream,
but that’s really not even technically a CBCT, is that correct, in
your view?
Shawneen Gonzalez: Well, the cone beam
CT is named a cone beam CT because it all has to do with how the image is
captured. So, in medical radiology, the CTs, like if you would go to a
hospital and get a CT, a computed tomography scan, it’s made with
radiation in the shape of a fan, so you get all these different slices and
they’re fans of radiation that image you. The cone beam CT is named
because the shape of the radiation is in the shape of a cone. So like a
traffic cone that you’d see on the road, you drive around those big
orange cones, that’s the shape of where the radiation comes out of
the x-ray source, and it’s computed tomography because we’re
using x-rays and it’s going to be 3D imaging, so they can compile
them all together to make it a cone beam computed tomography. And
currently, everything in dental right now that has 3D imaging capabilities
falls under cone beam, um, computed tomography, but yes, there are a few
machines that are not necessarily true cones of radiation, which might be
why they’re not truly saying that it is CBCT unit under that
definition.
Howard
Farran: Is it, I mean,
obviously when we say to our patients that we’re going to use a CBCT,
I mean, that’s Latin, Greek, that makes no sense, do you think it
should, could be just called to the patients 3D? –
this is our new 3D x-ray machine, we used to have 2D. Because everybody
understands a 2D movie at the big screen and the you put on your 3D
glasses. Is calling it 3D, would that be appropriate?
Shawneen Gonzalez: I think to simplify to patients, yes, using the term 3D
is more than acceptable. Also, maybe correlating it how it relates to a
hospital CT, saying that it’s similar to that, but a lot less
radiation dose because we’re not worried about soft tissues,
we’re looking at just the bone and the
teeth.
Howard Farran: So, when you say a hospital CT, you mean CAT
scan?
Shawneen Gonzalez: Yes, CAT scan is the old term that has…a lot of
people are still familiar with for a CT, which is computed tomography, some
people, yes, will still call it a CAT scan
though.
Howard Farran: So that’s where CAT scan comes from – CT,
computed tomography?
Shawneen Gonzalez: Yes.
Howard Farran: Okay, very good. Um, you probably think I’m old,
senile, and have dementia.
Shawneen Gonzalez: Nope. No, not at all.
Howard Farran: Okay, so how, um, so how many… there’s
150,000 dentists in America, uh 120,000 general dentists, 30,000
specialists – how pervasive is 3D now, um, in dentistry? I mean, do
you think there’s 10,000 units, 20,000 units of the nine specialties,
has it entered, uh, more in some specialties than other or, where is this
hot and where is this not, and as of today?
Shawneen Gonzalez: Well,
for starters, I think at this point, finally, I know that sounds like
it’d take a little while, all the schools should at least have one
cone beam CT unit, which is obviously very good. Schools are supposed to be
ahead of the game, but not always unfortunately. As for the general dental
population, I don’t have a number, but I can tell you a few
specialties, for sure perio and, you know, implanting, implant sites,
that’s been really big for cone beam CT, as well as oral surgery.
Oral surgery loves to see it, especially for those mandibular third molar
extractions. They want to see if it’s an impacted third molar, where
is it in relation to that nerve canal, so that they don’t cause any
permanent damage to the patient, or to even see if it is even possible to
extract those teeth. As, um, it is growing in the general dental population
– a lot of those smaller, fixed small size cone beam CTs that just
show maybe like five teeth in a quadrant, so it is growing a lot. Uh, I
wish I had a, a sheer number, but any time we talk to any of the people who
sell these things, they don’t want to give us numbers for obvious
reasons – it’s their little secret,
so…
Howard Farran: And, or, and as…are any of these working well
enough for an endodontist where he can just say, okay, is this failing
because it’s a fractured root on like, say, a maxillary molar
or…any of these machines good enough for that, in your
opinion?
Shawneen Gonzalez: There are
machines out there that are definitely capable of it. When it comes to
endo, the thing that they need to really be aware of is the voxel size, the
resolution size of your scan, and so some of the machines aren’t
capable of actually getting down to this, but what they AAE, the American
Association of Endodontist, and my academy, AAOMR, American Academy of Oral
and Maxillofacial Radiology, they did a joint position paper and said that
for endodontic purposes, if you’re looking for a
root canal fractures, if you’re looking for missed canals, you want
at least a .2 mm voxel size, or resolution slice or smaller, and there are
several machines now on the market that do provide that, but realistically
for endo, the smallest you can go, the better. So, for example, there are
some out on the market that are .09 mm, and that would be ideal for an
endodontic purpose to evaluate a tooth.
Howard Farran: Do you know off the top of your head if my Carestream
was on that list?
Shawneen Gonzalez: Carestream does have the .09
actually…
Howard Farran: Right on.
Shawneen Gonzalez: …it depends on what number of Carestream you
have. Like the 9000, there’s the 9300, and I think there’s, is
there a 9500 on a Carestream? The 9300 I know for a fact does have .09 mm.
They, um, on the Carestream, just to give a heads up, they don’t use
mm, they’re going to use microns, so they’re going to say 90
microns instead of .09, but it’s the same
thing.
Howard Farran: Can you email me that paper so I can attach it on a
thread after your uh, podcast in case anybody wants to read that
paper?
Shawneen Gonzalez: Oh yeah, I can definitely do
that.
Howard Farran: You don’t have to be in the Secret Society to read
it or anything?
Shawneen Gonzalez: You know, I’m pretty sure you…I’m
pretty sure you don’t…actually, you know, that paper might be
freely available on the AAOMR.org website. They may
actually have it under their joint publications, but I will definitely
check out, if there first, and the secondly I’ll check and see in
that journal to see if that…because that’s where it was
initially published.
Howard Farran: Okay, Shawneen, this is your hour, it’s not mine.
I’m just honored that, like I said, I’ve been a big follower of
yours on, social media, Twitter, I just think, I think you’re an
amazing person. So let’s start with, let’s start with - I would
assume about 90% of general dentists have not adopted this new technology
yet.
Shawneen Gonzalez: Yes.
Howard Farran: So, I want to start off with what should a dentist be
offering…she’s practiced ten years, she’s got digital
radiography, she has a pano machine, she has a SAF, these things are about
a hundred grand, right?
Shawneen Gonzalez: The cone beam CT?
Howard Farran: Yeah.
Shawneen Gonzalez: Yeah, that’s on the low end, but
yes.
Howard Farran: Yeah, that’s the low end. So, these could be a
hundred to a hundred and fifty, right?
Shawneen Gonzalez: Yes
Howard Farran: So start with the big picture of, first of all, what
should we be thinking about whether we make this big decision; number two,
is this bleeding edge or leading edge, I mean, is it a
now technology or a wait-and-see five or ten years? Because, to be honest
with dentistry, I’ve been out here for 27 years and I remember when I
got out of school in ’87, they came out with a $50,000 yag laser, and
like 1,000 dentists jumped on it, and then about five years later,
everybody said, that was a bad idea. I didn’t do anything with it.
And now it’s just a coat rack. Air abrasion hit the market hard and
about 5,000, 10,000 dentists bought it, and then after a year or so,
everybody said, you know, that really makes a huge mess and I’m going
back to a diamond burr or carbide burr. So tell us, Shawneen, is this
bleeding edge or leading edge, and if we assume 10% of the dentists have it
now, in ten years, what percent do you think will have it? Do you think it
will be 20, 30, 40%? Talk about that.
Shawneen Gonzalez: Okay, well
first of all, the first question that anyone has asked, general dentists,
specialists, if you’re considering purchasing a cone beam CT,
obviously the cost is very expensive. One thing I’m not a fan of that
a lot of the sales reps will do when they try to push these is
they’ll say, "Oh, well you only need to do maybe 15-20 scans a
month," and somebody will think, "Oh, okay, that’s not bad." But, you
have to look at your current population and go, how many scans would I
realistically need right now anyways? I mean, if I only need one or two a
month, where am I going to find my other potentially 18 scans a month, in
the sense of am I going to start pushing unnecessary radiation on patients
or am I going to market this out to other people?
So, I’m not a fan of that kind of sales marketing tactic, so
definitely ask yourself "How often am I doing scans?" I mean, is this just
a once a month type of thing? If so, maybe there’s another place to
get your imaging done. If this is something like almost
everyday you’re like, "Man, I really wish I had this in
my office," then you might want to seriously consider this as something I
really need to do.
Obviously, as a radiologist, I’m not keen on excess radiation to
people just for the purpose of because you have essentially the biggest
newest shiny toy. It’s not meant to be used that way. We still need
to be very, very careful with that and the radiation doses we’re
giving to our patients, especially any patient who is a child. So, those
are definitely questions to ask.
If you are starting as a general dentist to get into implants really heavy
and you know that you’re going to be needing to use a cone beam CT if
you are going to say, "I don’t feel comfortable placing an implant
without a cone beam CT," you know, maybe a cone beam CT is right for your
office then. So, you’ve got to ask yourself a lot of questions of how
often are you going to use this, but also to make sure your population is
people who actually need this information.
And when you have the cone beam CT though, then you also need to be doing
lots of CE to stay on top of everything, not just you, your entire office,
to make sure that you guys are keeping your radiation doses low and using
the machine to its best functionality for your patients. You want to
improve their oral health, not just get a scan to see if there’s
something going on. There should be a reason for it.
So, as for bleeding edge, this is the thing right now or if
everybody’s going to wait five years, cone beam CTs have actually
been around since…well, they were discovered back in 1997, came into
the U.S. in the early 2000s, I’d say about probably between 2005-2008
is kind of when they really started to skyrocket on the market and when all
the schools finally were starting to get their units. At this point, I
would say it’s starting to become, it’s not standard of care,
it won’t go there - that’s a legal term, I’m going to
stay out of that, but it is starting to become more common day imaging for
certain procedures, implants, those third molar extractions, bony lesions
to determine where they’re at, to get a biopsy or to remove those as
well.
I think if you wait five years, you’re going to see a lot more
offices have them. If we go with that assumption of, say, 10% right now,
I’d say probably be safe in the next 10 years to say that maybe we
might double in ten years and add 20% of offices will have them, maybe due
to improved image quality, but also because if there’s more on the
market, maybe the price will go down a little bit, making it a little bit
more accessible for not only the patients, but also then for the office to
buy it and then provide it to their patients.
There’s always going to be new imaging coming down the road. I know
right now people are really looking at MRI. MRI machines cost about a
million dollars, so there’s just no way that’s coming into
dentistry as in a general dentist buying any of those anytime soon, and
that’d probably be more just going off to a hospital, but for the
time being, I think cone beam CT is going to keep coming in. It’s not
to replace 2D imaging – we still need 2D imaging right now for our
bitewing radiographs, but it will become more standard.
Howard Farran: Who gets credit in
’97 for inventing this CBCT?
Shawneen Gonzalez: Uh, the very first one that came out on the market was,
it was in Italy, and it was the NewTom – that was the very first one
that ever came out on the market. It looks like a
CT.
Howard Farran: Are you saying Newton, like Sir Isaac
Newton?
Shawneen Gonzalez: No, NewTom, like the word new, N-e-w, and then its
capital T-o-m.
Howard Farran:
Huh.
Shawneen Gonzalez: NewTom, yep. That was the
first.
Howard Farran: They brought us pizza, lasagna, and CBCT,
huh?
Shawneen Gonzalez: That they did, yep.
Howard Farran: What a great country. I love that country. I want to
start with, who’s the father of medicine Hippocrates, the
Hippocratic Oath, first do no harm.
Shawneen Gonzalez: Yes.
Howard Farran: So talk about the, I always think back in my
day, the thing they scared us about the most was exposure to the thyroid.
Is thyroid still the most sensitive area we radiate in dentistry, and
will you talk about the thyroid collar and, and how it’s not
being really used with CBCT – will you talk about that for a little
bit?
Shawneen Gonzalez: Okay, so for…obviously yes, I’m not a fan
of radiating people just to radiate them for any reason whatsoever.
Thyroid, yes, it is going to be the closest radiation-sensitive organ that
we have. I mean, it’s right just there in the neck, right next to the
mandible. So, for that reason, you are supposed to be very careful. They
using a thyroid collar on a cone beam CT is, actually quite a heated
debate. I was just at my radiology meeting a few weeks ago, and
you’re going to find papers out there on both sides. You’re
going to find some papers out there that say you must put a thyroid collar
on because it’s going to reduce the radiation dose to the thyroid.
You’re going to find other papers that are going to say no thyroid
collar whatsoever because if you capture even a
little bit of that thyroid collar in your field of view, your scan,
you’re going to decrease your actual image quality. So, it’s
kind of interesting in that sense.
One way that will help is, for
starters, if you have a machine that can do different sizes of scan size,
choose already the smallest scan size that you need to capture the area
that you’re looking at instead of just, say, doing the big one and
doing the entire head every time. Also, one way to think about thyroid
– kids, they’re going to be by far the most sensitive. So, if
you’re ever imaging a kid for any reason, that thyroid collar should
always be on. They’re still growing, that thyroid is just extremely
sensitive. I’m not saying, as adults, you should totally ignore still
be putting the thyroid collar on, you just have to be aware, is it going to
be in your field, your scan, or is it not. So, if it’s not going to
be in your scan, throw it on. If you can somehow throw it on, but maybe say
tuck the sides down right by the angle of the mandible to help so it
won’t be in your field of view, that’s great. Any protection
you can give to those organs is always a good thing.
Howard Farran: Huh, and I wonder why the thyroid would be more
sensitive to radiation as opposed to the brain, the pituitary, all the
glands in your head. I wonder why that one’s more
sensitive.
Shawneen Gonzalez: You know, the brain is still very sensitive to
radiation, but it takes much higher doses to make any permanent damage to
your neurons in your brain versus the thyroid needs a lower dose of
radiation to cause any damage, and that’s why it’s just one of
those sensitive organs like the gonads and blood marrow cells, all those
kinds of situation. They all kind of got clumped together due to all the
previous research where people were irradiated, and then they saw what
types of disease, unfortunately, that they were cropping up
with.
Howard Farran: Huh,
I’m surprised my staff hasn’t volunteered me to be studied on
that disease. So I have to tell you that, being on Dental
Town all day every day, I do have to tell you one positive note on CBCT
– you don’t ever see buyer’s remorse. There was a lot of buyer’s remorse with, $50,000 lasers 25 years ago or air abrasions, I mean, I can’t think
of one post on Dental Town where someone said… not to be funny, but it’s kind of like once you
see a CBCT, it’s not like you want to go back to a
pano.
Shawneen Gonzalez: (Laughs)
Howard Farran: I mean, because, you know, not many panos you look at
and just say, That is just too much information, but almost every CBCT
everyone looks at, it’s like, Oh my God, you get…I mean,
you’ve just got to be humble, and say, That is way over my head. So what is your membership now up to,
specialties? You passed 200 oral and maxillofacial board-certified
specialists, didn’t you?
Shawneen Gonzalez: We, I think…board-certified
active, and I say active as in, not retired, still actively either
teaching or working in private practice is actually about 140 to 150 right
now. Actual members of our academy who may not be board-certified in a
sense that whether they were trained here in the U.S. or in a foreign
country and just either didn’t take the test for, you know, whatever
reason, because there are people, we do have a few people like that –
yes, we are closer, over 200 members in that sense, and that includes the diplomats as well.
Howard Farran: Since, since the Italians invented it, are the exempt
from being called a foreign country?
Shawneen Gonzalez: No.
(Laughs)
Howard Farran: Are they the base country
now?
Shawneen Gonzalez: No, they’re not the base
country.
Howard Farran: But, then maybe they should be. And so I know you’ve accepted a new position in an
Oregon dental school…
Shawneen Gonzalez: Yes.
Howard Farran: …which is an outstanding dental school,
I’ve been there many times, in fact, one of my favorite dentists
in the world in Arizona, Kelly Bradley, is a graduate from that school. Do
you know Kelly Bradley?
Shawneen Gonzalez: No, I do not know who that
is.
Howard Farran: Yeah, she’s in Bullhead City and, one of the
sharpest, dentists I’ve ever met in my life, and she’s from
that school, but so obviously, if a dentist is going to be
honest, at least nine times out of ten you’re going to
take a CBCT and see things you don’t know what they are. Are you,
yourself, can dentists send you an
email…
Shawneen Gonzalez: Oh yes.
Howard Farran: If they bought a CBCT and they’re like, Shawneen,
what is that thing on the right? Are you doing that, and how does a
dentist contact you?
Shawneen Gonzalez: I’ve got two methods, kind of, that I offer to dentists.
One is kind
of like a quick look type thing when a dentist could take a screen shot or
make a, like a JPEG image off of their imaging software and send it off to
me and just give it a description, saying, "Hey, just wanted a quick look
– can you take a look at this?" And so I can look at it, and
it’s called a quick look because I don’t spend too much time. I
obviously just look at like one or two images, and I’ll, you know,
give a little radiographic description of it and say, Either A- "Here’s what it is," sometimes it’s pretty obvious, other times I
may say, "This is suggestive of this and you might need, to look
at referring it out if you’re wanting a biopsy and talk it out with a dentist."
The other option is is that I have a website where people can actually upload an
entire Dicom data set to me, and then they send their referral in with me,
as well, and then, with that, I will them download it on my side, provide a
detailed radiology report, and then send it off to the dentist and talk
with them again, answer any questions, but that way I’m not looking
at just the area in question, I’m looking at everything. I mean,
sinuses, we’re looking at cranial skull base if it’s captured,
the cervical spine, airway, the neck, the other teeth that are on the scan
that maybe somebody may have just been looking in one area and maybe kind
of forgotten to look at everything on the scan, so it’s just a nice,
thorough look-through essentially is what the report is that I provide for
offices that are interested.
Howard Farran: Yeah, and go over, go over that name – I was
wondering, it’s drgstoothpicks.com.
So…
Shawneen Gonzalez: That’s my
educational website. My one that I do the actual reports through is
actually legacy3d.com, so just L-E-G-A-C-Y-3-D.com, and there’s a place where you can do a file upload, it goes
through a company I use the software called, well they changed their
names…what are they…Hightail? It used to be called, you send
it, it’s called Hightail.com. It is HIPPA-compliant, so you are
safe…
Howard Farran: Hitell…H-I-T-E-L-L.com?
Shawneen Gonzalez: Hightail is H-I-G-H and then tail, like a dog’s
tail, T-A-I-L.com. It’s one of the few HIPPA-compliant kind of
Dropbox software that is in existence right
now.
Howard Farran: Okay, the dentists in Colorado are going to think of
something else besides a dog jumping high.
Shawneen Gonzalez: (Laughs)
Howard Farran: So, then tell us all about your
other website, Dr. GS toothpicks – tell us about
that?
Shawneen Gonzalez: Yeah, my Dr. G’s toothpicks, that was
something that I got…
Howard Farran: Oh, "Dr. G's," oh, I got that. I was wondering what the S
stood for. I didn’t realize it’d be
possessive.
Shawneen Gonzalez: Yes, it’s like a Dr. G’s toothpix and then
the X is just kind of a fun play for pix for x-rays, because
that’s, you know, I talk about radiation and do all the radiology
stuff. I wanted something that was catchy, but also I was having the
hardest time coming up with my Twitter handle, because Twitter has a limit
of 15 characters, and my full name does not
fit. So, I figured I’d go with something a little more
creative.
Howard Farran: That, that is an interesting name, Shawneen. You know,
when I first saw your name, I assumed you were American
Indian.
Shawneen Gonzalez: Nope, I am not, but yes, the Shawnee Indian tribe is
very similar, I get that question a lot.
Howard Farran: Yeah, very interesting, and, but anyway, you just have two
websites, Twitter, I mean, you’re just…I mean, really,
you’re, a leap ahead…I love it when you, uh, send out a, um, an
x-ray [on Twitter] and say, "What is this?" and you start seeing how everybody starts
thinking and I’m sure most people are too shy to
make a guess. It’s just amazing.
Okay, so
we talked about that. So, so tell us…well, let’s go back to
the general dentist, looking at the CBCT. Obviously
implants, obviously wisdom teeth, roots around the inferior alveolar nerve and all that’s a
given.
Shawneen Gonzalez: Yep.
Howard Farran: Endo for missed canals
since… missed canals seems to be the number one cause
of, of root canal failure according to some of my endodontist friends,
but why did you say perio?
Shawneen Gonzalez: Well, for perio, it’s primarily for implants,
and with the implants they want to know, first of all, quantity of bone,
as, you know, where is the canal, especially in the mandible, but also in
the maxilla, if they’re going to be doing a sinus lift, they want to
be able to image the entire sinus so they can know how much they can lift
the sinus and pack on how much, you know, bone graft material they can pack
in there without occluding the sinus opening that drains in the nasal
cavity.
Howard Farran: Okay, very good. We have to talk with
patients all day long, and I love the internet. I have to tell you
honestly, I’m in Phoenix, Arizona, it’s a very middle class
neighborhood, 25% of my patients speak Spanish, it’s, it’s
very, it’s not Scottsdale, it’s not Paradise Valley, it’s a very family practice, I have to tell you
that, you know, three times a day in conversations, at least, a patient
will say, Well, I was reading on the internet, blah, blah, blah, blah,
blah, and I like it – I’d much rather have that then practice
in, uh, 1900 when four out of five Americans couldn’t read or write,
I think that would have been less fulfilling, you know, to just have some
person come in there and be completely, illiterate, I love
that.
But could you give us dentists and hygienists and
assistants some verbal language about people who
just refuse x-rays because they don’t want any radiation, when at
least, in my office, we’re back here thinking in our head, Dude, you
live in the desert, you know, if you have these views, why don’t you
move to Alaska or Antarctica or Buenos Aires, I mean, you shouldn’t,
you know…why, how can you say that when you live in a land
that’s so much radiation, there’s only like cactus and
scorpions running around, and is for me to even
think that, is that even a correct way to think, or is dental radiation so
different than…I mean, when you walk outside for six months a year
in Arizona, that sun just beats you. I mean, it’s like wow, I mean,
you can feel the rays.
Shawneen Gonzalez: Yes.
Howard Farran: So, is there any language, anything aimed at like just, you know, a 6th grade, high
school…not, not insulting the patients that they’re like a
6th grader…but, from a non-technical point of view, some
verbal conversations you can give us to talk to our patients who are
refusing x-rays, because of radiation.
Shawneen Gonzalez: Well…
Howard Farran: And obviously a high-educated mother doesn’t want
her baby irradiated, I mean, you’ve got to give her credit for
that.
Shawneen Gonzalez: Yes, and I mean, it’s good I think that patients
are aware, it’s always a good thing for patients to be aware and kind
of just want to make sure that there’s the, you know, the do-no-harm
thing again. Well, one thing to start with,
that every office should start with that will help, is looking at the ADA
and the FDA, prescription for ordering radiographs. They came out with
guidelines back – and they are guidelines, it’s not, you know,
set in stone or anything, came out with guidelines back in 2004, they
updated them just in 2012, and it gives you just a really simplistic,
one-page table that says, based on your type of patient, is this a new
patient, is this a recall patient, what type of dentition do they have,
is it mixed, is it permanent, is it all primary, and then you also look at
the caries rate, and you can kind of follow the table across, and determine
how often should we, first of all, be getting radiographs on a patient. So,
if you were to have an adult come in your office, based on
this…
Howard Farran: Okay, can you email me that, too, so I’ll attach
that?
Shawneen Gonzalez: Yeah.
Howard Farran: Okay, because what I like doing on my, podcasts is
we, we always do a transcript, so if you’re out there riding your
bike right now or mowing your yard or riding a
horse…
Shawneen Gonzalez: Yes.
Howard Farran: …you don’t have to stop to write all this
down, so you’ll email us that, too.
Shawneen Gonzalez: Yes, yep, I can definitely email that to you.
That’s one thing that I…this is something I like to get out to
as many people as possible. So, for this, just…I’ll give you
an example. Say you’ve got an adult patient coming in the door who is
really adamant, no radiographs, you look at their chart, they are, got
great oral hygiene, they have a very low caries risk, you haven’t had
to really do anything in their mouth, it’s pretty much they come
in, they get their teeth cleaned, you do a look, and you’re like,
wow, everything looks awesome. According to the guidelines, you can go
anywhere from 18 months to 36 months before doing bitewing radiographs the
next time the patient needs to come in. Now, I realize that’s
essentially going anywhere from a year and half to three years, which is,
you know, you have to take in your own personal professional judgment into
this, as well, but some patients maybe like to hear that they don’t
need it every six months, every year or so, if they’re keeping their
mouth really clean.
So, maybe it could be motivation for a few people
– hey, let’s take care of your teeth, let’s get these
caries rate down, we’ll need less radiographs. Obviously those who
have a high caries rate are going to fall more in that six to 12 month process where they’re going to need radiographs just because they
keep cropping up with new stuff every time they come in. So, that’s
one thing to start off with. If you’re already using that, that will
help decrease your radiation to the patients.
Like you were saying though,
there’s radiation everywhere. We can’t avoid it. It’s
outside, it’s, you know, it’s in our house, it’s when we
fly, just going up at a higher elevation, or for you guys in Arizona, I
mean, Flagstaff is pretty higher elevation, too, so even just going to
visit Flagstaff for a little while or if you lived out in that area, I
mean, that higher elevation, you’re getting more radiation there than
you would down at sea level. So, you could try to explain that to them.
Sometimes with people who get on the internet, one thing that might help
– maybe, you’ve got to be very careful with this one, is if
they do a radiation dose calculator, so if they type that in to, say,
Google, Yahoo, whatever their search engine is, there will be a lot of
different websites out there. There’s one, I think it’s the
NRC.gov website, has a radiation calculator where you can choose where you
live. It’s for those in the U.S., where you live in the U.S., how
many times you travel, whether or not you have then, say, false teeth,
whether you have a pacemaker, smoke detectors in the house, all those
little things give off radiation, and then at the end, it gives you a
pretty little pie chart of how much radiation each year you get based on
the different things. And radon is the number one for everyone here in the
U.S., most of our background radiation. So, I mean, those are other ways
that you can kind of try to explain that radiation is everywhere, we
can’t control it. Um, obviously yes, the radiation we get from the
radon and all those other stuff in our house is a little different than the
radiation that we get from dentistry, but again, if you’re following
those guidelines, that will help keep it down, as well as making sure your
technicians are trained, so that you’re doing less retakes, always a
good thing, too. So, it they’re really trained in the sense that you
would need a perioapical radiograph and they can get it on that first shot
instead of needing three or four, that’s going to help
also.
Howard Farran: Is there any, um, apples to apples comparisons of, uh, a
set of bitewings or a full mouth…so, I mean,
you’ve…back in the day, they say, you know, bitewings is
equivalent to being outside in the sun for 10 minutes. Is that a fair
statement or, is there anything…
Shawneen Gonzalez: It’s kind of… it’s
hard. And I say it’s hard because of the sense that it kind of
depends on where you live. So, when I was in Lincoln, Nebraska, and this
also where it gets a little tricky, in Lincoln, Nebraska, at the dental
school, we were using Phosphor-plate system and we had rectangular
columnation. So we didn’t have a round cone, we had a
rectangular-shaped cone. And so using the Phosphor-plates with the
rectangular columnation at about 1,100 elevation, 1,100 feet above sea
level, a set of four bitewing radiographs was about a half day background
radiation. So, you have to look at, uh, what’s your image receptor,
are you using film, S-speed, D-speed, are you using digital, are you using
sensors, phosphor-plates? You need to also look at
then…
Howard Farran: You said bitewings equaled a half day’s
exposure?
Shawneen Gonzalez: In Lincoln, Nebraska, for the phosphor-plate
system…
Howard Farran: Yeah.
Shawneen Gonzalez: …with a rectangular columnation.
So…
Howard Farran: Wow.
Shawneen Gonzalez: …there’s like…there’s kind
of…it depends on your elevation and where you live at, depends on
your, for your actual x-ray, and is it a round cone, rectangular, are you
columnating it down to rectangular, and then also, like I said, are you
using film, are you using digital, and kind of your exposure time.
We’ve obviously, in the last 20 years, have decreased our radiation
exposures to patients immensely, but a lot of our patients, especially for
those who’ve been going to the dentist for a long time, they
don’t realize this, and they’re not going to probably
comprehend that we’re down from, what used to be a
second exposure down to a tenth of a second
exposure. And they wouldn’t realize that sitting in the chair, they
just feel the uncomfortable apparatus kind of in their mouth and they just
know that you’re getting your image you need to do your
work.
Howard Farran: And, I want to go off into a completely different
area, but one that really bothers the general dentists, and that is back, you know, back in the day, it seemed like so many of the
materials did not show up on an x-ray. So, for a general dentist taking a
bitewing the filling, you know, 25, 30 years ago, half the time you
didn’t know, is that a base, is that a liner, is that
decay... are we doing, as a profession, a lot better where all the
man-made cements and bases and liners or are carrying something so it shows
up on an x-ray, or what is your thoughts on that?
Shawneen Gonzalez: Um, most of the liners and the cement I’ve seen,
yes, now are very radiopaque, in the sense that you can tell it is
something man-made, it does not look like anything, it’s more
radiopaque than the enamel, the bone, all that other stuff, so it’s
evident that this is something that a person, a human being stuck in the
mouth. There is a weird thing, though, with the composites, composites
are always tricky, that you start out, used to be radiolucent, and then
they went radiopaque, and for some reason, I’m not quite sure what
the manufacturers are thinking on this one, they’ve started making
more of the composites to have a very, very similar radiopacity to enamel.
So, when I’m teaching the students, a lot of times, I mean, I know
what the DEJ of a tooth looks like on a radiograph, I have the experience
of looking at more radiographs than they do, but when they’re
starting off, if it’s a smaller, say occlusal restoration, they
don’t catch that that’s actually a composite on the radiograph,
and sometimes because they’re still
new, when they look in the mouth initially, they don’t also see it
because they’re still trying to figure out the normal anatomy of the
tooth. So, that’s one that I’m not quite sure why they’re
trying to mimic the radiopaque…
Howard Farran: I, It confuses the heck out of me. I mean, the main
thing that confused me with composite makers is why there’s
nothing in there antibacterial. I mean, I was, I always viewed dentistry as
a biological problem. It seems like all of the composite manufacturers
always view it as a mechanical engineering structural engineering problem.
They, they want a certain material of wear and strength, and I’m
like, this is going to fail from an infection of recurrent decay underneath
it. It’s not going to break in half. That’s not the
problem
Shawneen Gonzalez: Yes.
Howard Farran: The problem is antibacterial, and they always want to do
wear and strength and megapascel and all that stuff. But, yeah, I think
it’s _____. Um, is it safe for you to say to dentists, um, when
we’re not sure? Um, you know, a lot of times with these composites,
you see…an MOD composite…
Howard Farran: And sometimes you see a radiolucency underneath, um, but
if it’s just fairly uniforming, I, I always think of streptococcus
mutans not having any order to its growth, I just see it as like a random,
chaotic infection. So, if it looks fairly linear, is that always a good
rule of thumb that it’s probably
not…
Shawneen Gonzalez:
That’s exactly what I teach my students, exactly. If you see a
radiolucent area underneath a restoration, a composite restoration
especially, and it’s got a nice, sharp line on it, really well
defined, that’s going to be more of a man-made cut to the tooth.
You’re right, caries, when it grows, it just goes to town. It’s
going to go all over. It’s going to be more diffuse radiolucent area,
not a nice, sharp edge. They don’t…the bacteria doesn’t
make in rows down through the tooth like that
whatsoever.
Howard Farran: And, also back in the day, um, I was formally taught
that what we see on a bitewing is actually only 40% of the size of the
lesion. Twenty-seven years later, is that still a good number or, will you
talk about that?
Shawneen Gonzalez: I would have to say that number pretty much actually
still stands true, especially with our faster speed film, so like F-speed
film versus even the digital imaging because we’re using less
radiation, the size of the caries that we can see on a radiograph, yes, is
always smaller than in the mouth, and I’d say about 40-50% smaller
than what you’re going to see. So, a lot of what people are going
with digital imaging is if it’s half way through the enamel that
means that when you get in there and you go and remove it, there’s a
good chance you’re already touching the
DEJ.
Howard Farran: Yeah, one thing I’ve done with my long term hygienist, and that is whenever we would disagree when they would say,
I’d say that’s a DO on #3, and she’s day, I’d put a
watch, so I’d always put a, a note on the chart, so when that
patient, when I was doing that, as soon as I drilled into that and then I
would go get the hygienist, and I’d make her sit
down and spoon x-rayed her, and she’d go back to the x-ray and think,
wow.
Shawneen Gonzalez: Yeah.
Howard Farran: And I’d always try to teach that point because
it’s, uh, and a lot of that stuff you have to associate the vision of
the radiograph with the show/touch/feel of drilling on that
tooth.
Shawneen Gonzalez: Yes.
Howard Farran: So what else did you want to talk about? I wanted to ask you if there’s, we always see advertisements for
other technologies, for caries
indication.
Shawneen Gonzalez: Yes.
Howard Farran: Um, and there’s lots of companies. I mean, and
over the years, just like, some have been lights, some have been wands,
some have been…
Shawneen Gonzalez: Yeah.
Howard Farran: …dyes and stains…is there any
other…if, if I took away ______ radiograph
machine…
Shawneen Gonzalez: Yes.
Howard Farran: …and took out, take out all those radiation
______, are there any other technologies that, um, that have your attention
or you think, um…are here now, leading edge not bleeding
edge?
Shawneen Gonzalez: You know, when it comes to all the new stuff, I’m,
my interest is definitely peaked, but I haven’t seen enough to make
me go, Yeah, that’s definitely what I want to, say, even be telling
the students about. Because a lot of times
I’ll be talking to the students, they’ll ask me, say if I go
off to like the ADA meeting which I know was just last week, I
couldn’t make it this year, but they’ll even ask me, you know,
or I’ll ask them, have you guys been taught about this or this and
that, so right now, I’ve got to say, when it comes down to it, the
bright light, that really is the ideal. The only one I’ve seen that
is effective, I’m still waiting for a little bit more information on
the other guys that are coming out yet as to whether I’m sold on,
yes, I want to be telling students, or any practitioners. I mean, when I go
off to CE courses, you know, this is an interesting thing, you definitely
want to be looking into it.
Howard Farran: I, I, um, I like the bright light on flat, thin
incisors…
Shawneen Gonzalez: And anterior teeth.
Howard Farran: …but nothing in the
molars…
Shawneen Gonzalez: No, that, that’s the problem. It works for the
anterior teeth, I agree, the posterior teeth,
you’re…they’re just a little too thick there.
(Laughs)
Howard Farran: And, and in my office, nine out of ten interproximal
cavities are going to be on the molars and premolars,
and…
Shawneen Gonzalez: Exactly, and that’s what the problem
is.
Howard Farran: …and by the time you have interproximals on the
anteriors, you pretty much are doing an MOD on every tooth in the mouth
anyway. I mean, they’ve got a huge, uh, dietary
problem.
Shawneen Gonzalez: That’s true.
Howard Farran: Um, so
um, so let’s go back to this dentist, um, I’m
a…let’s say it’s a general dentist. Um, I would think
80% of the general dentists do not place implants.
Shawneen Gonzalez: Yes.
Howard Farran: Um, I would think 80% of the general dentists do not
pull impacted wisdom teeth.
Shawneen Gonzalez: Yes.
Howard Farran: So, if you were a general dentist and you did not, uh,
place implants and you don’t want to place implants, there’s a
lot of dentists that they just say, Shawneen, um, you know, I really
don’t like to do the blood and guts surgery
stuff.
Shawneen Gonzalez: Yes.
Howard Farran: I really don’t want to place an implant, I really
don’t want to take an impacted wisdom tooth, um, if you…if you
were that dentist, and this machine was six-figures, um, so I need to buy
that machine. I mean, can I be a good dentist without spending $100,000 on
a CBCT if I don’t place implants or pull impacted wisdom teeth? Can I
still be a high-tech, high quality dentist?
Shawneen Gonzalez: I think you can, but I think that you would also want to
have an avenue somewhere that, should you find a case where you have some
pathosis that you want more information. Say you see something on your 2D
images on your perioradiograph, your pentomagraph or something, you see
something and you’re like, I don’t feel comfortable with this,
this looks like there might be something going on, you’d really want
to be able to have that avenue to say, here, I’m going to refer you off to, say,
if you’re next to, you’re near a dental school, you know,
I’m going to refer you off to the dental school and get some
additional imaging because I just want to get a better look at this, and it
may turn out to be it’s just their normal bone pattern that’s
mimicking disease, which happens, or it may turn out to be something more
serious. But, the point is is that you were able to at least help them take
the path necessary so that the person who then does go in there and remove
it will have all the necessary information to do the best job possible,
causing the least amount of harm to that patient.
Howard Farran: And if you’ve got that x-ray, be more specific
on your website, because I know a lot of dentists, they’re just
not that…a lot of them, especially my age, are not that tech savvy,
how difficult is it to upload one of these to your website? I mean, what
all is involved?
Shawneen Gonzalez: Um, well…
Howard Farran: Are you, are you going to download that x-ray on your
machine to like a, uh, like a thumb drive, and then, uh, you know, how is
he going to get that…how is he going to get that information out of
his CBCT, and into the internet, into your
website?
Shawneen Gonzalez: Okay, so what they do is, first of all, on the cone beam
CT, there’s usually…now, each machine and software is a little
different, but there’s usually two methods you can export the data.
One is to export it and burn it with a viewer, which is something that,
say, if you’re sending it off to another office to be viewed at or
the patient wanted a copy of it. Another is to export it in Dicom, which is
D-I-C-O-M format, and so what you would do is you would actually export it
in Dicom format, maybe onto your desktop of that computer or into
a folder probably is what I would recommend
because if you do multifile, there will be like anywhere from 300-500
files, so you’d put a file folder with that patient’s name, and
then for, on the website, the legacy3d.com, you go down on the front page
to the file transfer, and you click there, and then you actually can just
grab that folder and drag it right over to the box when that page opens,
and then, in your email, you put your email in, and you put any information
you want to specifically be looked at on that report in the subject area
and down in the actual area of the email, and then you’d hit send. It
will upload – just to give you a heads up, those are big files, it
may take anywhere from five to ten minutes depending on your internet speed
and how fast your computer is, but then that’s really it. It’s
really a click and a drag, fill out your information, and then hit
submit.
Howard Farran: Um, yeah, I notice everybody who talks about the Dicom
file, I, I didn’t hear, get the name of the first file, but the
second one, the Dicom, that seems to be what everyone is
using.
Shawneen Gonzalez: Well, Dicom is actually something that medicine came up
with. I can’t remember when they did, but the problem was is that all
of the companies were coming up with their own thing. So, like Carestream
would have had Carestream only type images instead of, say, A JPEG. And so
Cerona would have Cerona-only images and that could only be read by Cerona.
So, Dicom was created so that any hospital at all pretty much in the world,
not just the U.S., in the world, can transfer their images, and they can be
viewed at that hospital. Dentistry, uh, with cone beam CT, we were a little
slow to start off, everybody had these capabilities, but they’re
finally starting to all have now, the Dicom format because this is what we
should be using, because it has all the patient information, everything
like that, so you
must be very careful, obviously
HIPPA-wise, when you submit these images anywhere, but it’s just the
only way to ensure the image is seen initially as how you were seeing it,
too.
Howard Farran: Yeah, we, we see that in, uh, CB, in uh, CAD-CAM, too,
where, you know, they’re closed for proprietary systems and then
there’s open formats and, uh, laboratories have to deal with that a
lot. Um…
Shawneen Gonzalez: Exactly.
Howard Farran: Um…so, um, back to the, um…back to the,
uh, forgot, uh…Oh, I remember what I was going to ask. What, what is
the turnaround time? Like, if I have a patient and I get that CBCT, I
upload it to you and I say, Will you look at this, what kind of turnaround
time is he looking at?
Shawneen Gonzalez: Um…
Howard Farran: Is that a week to 10 days, is that 38 hours, is that a
month?
Shawneen Gonzalez: Um, five day…at the end, I’d say five
business days, but it all kind of depends on how many other cases I have. I
try to realistically do it within one to two business days is what
I’m shooting for. Obviously the more cases I get, it’s going to
be a little bit more difficult to get that quicker turnaround, but I, I
especially want to, but also if a dentist is saying this urgent, if they
were to mark that and say urgent, can you please get this back to me as
soon as possible, it might help them jump the pile so that I can try to get
that one out maybe within more like a one-day
turnaround.
Howard Farran:
Wouldn’t it be easier if you just made all your students read them
for extra credit? (Laughs)
Shawneen Gonzalez: (Laughs) If only, except they don’t know what the
hell they’re looking at, that’s the
problem.
Howard Farran: So, I, I want to also say that, um, being an older guy
that, um, that you’d be surprised…you know, specialists would
do anything to meet a general dentist because, um, number one, they,
they’re B to B – specialists make their money from, uh, mostly
from, uh, other dentists.
Shawneen Gonzalez: Yes.
Howard Farran: Um, as opposed to dentists who are more B to C, business
to consumers. So, we, dentists tend to market, uh, to patients, and
dentists tend to market to other dentists, B to B, and I, I I, now granted,
I’m in a very huge city, but I don’t know a single oral
surgeon, uh, that if you said, Can my assistant take over my patient
Shawneen and take a CBCT, would you mind, um, they, they, everyone I know
is like, Absolutely. And I’m a general dentist, and I have, um,
probably about five general dentist friends who just pop in unannounced
every once in a while because I have an open-door policy. It’s like,
yeah, because I actually feel better, I mean, if you spend $100,000 on a
Carestream machine, but you want it used a
lot.
Shawneen Gonzalez: Yes.
Howard Farran: I mean, you don’t want the thing gathering dust,
so…and it’s a great social thing. I’ve always thought
the dentists who have the biggest social networks of other dentists always
seem to be the happiest, most motivated, and the people who, um, are the
most
withdrawn and the most introvert and the
most keep all their problems inside, usually are the ones that, um, some
day they just, you know, explode into thin air, and turn to being flat, so
I think, um, I think if you’re not sure if you need one of these
things, start, start talking to a specialist. It’s fun, it’s
social, uh, a lot of times they turn into your biking partners, your
jogging partners, swimming partners, I mean, it’s amazing how many,
uh, orthodontists start a Lifetime Fitness and all that stuff and
it’s a fun time. Um, so, I’ve only got you for ten more
minutes, um, what, what, what should we be talking about that I am not even
smart enough to ask you?
Shawneen Gonzalez: Oh, geez, let’s see. I mean, I go over lots and
lots of fun stuff. Uh, there’s lots of new stuff that is coming out
there on the market that’s obviously controversial. I’m going
to be actually doing a CE course, let’s see, in just a few weeks
about the bitewing modality on pantomograph or panoramic machines, and
just, it’s a short and sweet CE, they do a series of, like just
30-minute talks and the audience gets a chance to kind of learn
what’s the hot topic essentially, and I know that’s an
especially hot topic right now because of insurance reimbursement, because
offices have been buying these machines thinking this is awesome, I
don’t have to do bitewing radiographs anymore, I’ll just use
this one machine, I’ll get my, my pantomograph or panoramic
radiograph and then I’ll just click the bitewing feature and
I’ll get my bitewing radiographs. But, that’s an extraoral
image, and according to the ADA codes, bitewing radiographs are intraoral
images. So, they’re submitting them to insurance and insurance is
saying, No, we’re not going to pay these. These are not bitewing
radiographs. They actually have to be coded as an extraoral radiograph, and
they may not actually have much of a reimbursement if any reimbursement for
an
additional extraoral image. So,
that’s one thing that’s kind of hot topic right now, that I
know in California has recently been an issue for several
people.
Howard Farran: Shawneen, how close are we before, you know, um, when I
heard the, um, back in 2004 when Google was going public, uh, Sargie Bren,
Larry Page, they were talking about their, their true passion was not
search, that a business model, their true search…their true passion
was artificial intelligence. How close are we to that leap where the CBCT
or the radiograph runs through it and says, there’s a cavity on
enough areas demineralized on the mesial of #3 that that is a lesion. How
close are we to that? Is that 10 years out, 20 years out, is that Star Wars
stuff or is that around the corner?
Shawneen Gonzalez: Um, well, it’s a mixture of right around the
corner for some patients – I have to emphasize for some patients, but
for other patients, I think we’d probably be another 10, 20 years,
and it all comes down to existing restorations in a patient’s mouth.
You have a patient who’s got any existing restorations, they’ve
got amalgums, they’ve got even composites, they have had endodontic
treatment, they have, you know, ______ hanging out there, those all cause
artifacts, they cause streaking artifacts, and so because of that, we
cannot really see the interproximal of teeth very well for small lesions.
So you still have to rely on bitewing radiographs, they are going to be the
bread and butter still for those patients. You have a patient – no
restorations whatever, which we are trying to get more of those patients,
but there are still more patients though that are going to have existing
restorations, so if a patient has no restorations whatsoever, yes,
sometimes – I’m not going to say all the time, but sometimes on
a cone beam CT, you can catch those lesions in the enamel. But,
we’re
still…and that’s where the
ones that are just around the corner for. But, it’s a catch of how
many patients do you have that have zero existing restorations that would
qualify, and at that point then, why are you doing a cone beam CT which is
so much more radiation than say, bitewing radiographs, you know, that are
probably…there’d have to be some other reason why you were
doing the cone beam CT, because of the excess radiation still right now.
So, some people, yes, other ways, we got about 10, 20 years until they can
figure out how to get rid of that streak artifact which is a tricky, tricky
thing to do. So, we’re getting there, they’re trying, but
we’re not there yet.
Howard Farran: I want to ask you another thing that’s really
flying around the internet and, um, bothering a lot of dentists over a lot
of cities, and that is, um, you know, there’s just, there’s a
website that just keeps getting hit about what, what do 99% of all cancer
patients have in common – they’ve had a root canal. And it
shows all these pictures about how there’s still residual infection
at the end. Of course, when you talk to endodontists, they’re going
to say, Well, you have…your body interfaces bacterial in your mouth
and in your sinuses, in your eyes, your ears, downstairs, all, all these
places, um, but I want to ask you specifically, um, when a dentist sees,
uh, something at, um, a perioapical of a
tooth…
Shawneen Gonzalez: Uh-huh.
Howard Farran: …it’s had a root canal, it was five, ten,
twenty years ago…
Shawneen Gonzalez: Yes.
Howard Farran: The
tooth’s completely asymptomatic, but you see a little perioapical
radiolucency. Does that, does that always say, That’s a failed root
canal and you need to retreat that, ______ retrofill, or could that be a
radiographic lesion, scar tissue, uh, something else. Will you talk about
that?
Shawneen Gonzalez: Um, it could be exactly the kind of options you said. It
could be a failing root canal, which may still be asymptomatic because a
lot of times even normal teeth that haven’t been endodontically
treated may have that radiolucent area at the apex and are still
asymptomatic, they just haven’t flaired up. There is also the, like
you said, the fibrous scar. It just had fibrous healing instead of bone
healing. Uh, the difference is really going to be on a fibrous scar, you
should be able to see a pretty well-defined, kind of corticated radiopaque
border around it, indicating that it hasn’t changed. And also if
you’ve been following it over time at all with, say, 2D imaging,
you’ll see the size stays exactly the same. If it’s a failing
endo and there is actually some bad stuff down in there, it’s going
to keep growing over time. So, it’s one of those things, I guess, you
know, that are symptomatic and you’re, you don’t see nothing,
you say you had an endodontist just right next door, they take a look,
they’re not too concerned about it, they may say, Well, when they
come back in six months, we’ll do another periolithical radiograph or
something and we will evaluate, has it changed, has it not changed, if the
patient stays completely asymptomatic at that time. Those are always I
grade little on the more tricky side, watching it to see if it grows versus
also looking at just the edge of it, that radiolucent
area.
Howard Farran: So, I only got you for two more minutes, is there any,
any other, uh, any other areas you want to hit that I, uh, didn’t
ask?
Shawneen Gonzalez: Uh,
not that I can think of, other than like you mentioned with the website,
I’m always looking to see what other people, what other radiology
topics people want me to post on. It’s obviously primarily for my
students, but it has caught on and I have a lot of people around the world
now who are following my website. I do my little Find the Caries and Locate
the Object for image shift practice for anybody out there, students and
dentists alike, dental professionals, so I would just say if
anybody’s got some fun topics on radiology or topic in radiology that
they want me to hit on, you know, shoot me a message on my website, the
drgstoothpix or on Twitter, you know, that’s the same –
drgstoothpix, and let me know and I’ll see what I can
do.
Howard Farran: Well, I think the number one question every dentist is
America has for you is that, now that you’ve left Nebraska, are you
still going to be a patriotic, Big Red Football fan, or are you going to
throw them under the bus for some lowlife Oregon
team?
Shawneen Gonzalez: (Laughs) If I’m going to pick any college football
team, I’m going to pick where I went to dental school, and
that’s going to be UW, and that’s the Huskies.
(Laughs)
Howard Farran: Ah, right on, right on. Well hey, uh, I love your
energy, love your charm, I think you’re absolutely, um, brilliant,
genius…
Shawneen Gonzalez: Well thank you.
Howard Farran: …creative, your site’s amazing. Uh, if
you’re a dentist and you haven’t checked it out, uh, not only
do you need to check it out, you need to check it out with your hygienists
and dental assistants, and in fact, I, I do have you technically for one
more minute, so I’m
going to ask you, I’m going to ask
you one question. Um, I, I have this argument with dentists all the
time.
Shawneen Gonzalez: Yes.
Howard Farran: I believe when the hygienist reads, you know, looks at
the x-ray and talks to the patient, because, you know, a lot of times they
might thing, Well, the dentist is rich and has a nice car and lives in a
big house, he owns this place, but the hygienist, I mean, no one thinks
their hygienist is on commission or gets paid a dollar for every cavity she
finds. And they’re in there for an hour, and, and I, I, when
I’m in the other room doing some…cementing a crown and someone
asks my dental assistant a question like, Well, will you show me that, or
What is that…I, I, some dentists say you absolutely cannot answer
that question, you say, We’ve got to wait for the doctor, and for 27
years, I’ve always said, You talk to them like they’re your
mother, your brother, your best friend…what do you think about
hygienists and, uh, hygienists in particular, um, talking about radiographs
in front of patients?
Shawneen Gonzalez: Um, I think that they can definitely say what
they’re seeing on the radiograph, but they do want to also maybe
phrase, Hey, well, I see something here that may look a little concerning,
but we’re going to ask the doctor when he comes in, just to get his
or hers final opinion, and that comes, the reason you have to, they might
want to put that little disclaimer in is only because of the legal issue.
Legally speaking, yeah, and I know, I know what you’re saying.
Legally speaking, that some dentists are a little more like, No, they
can’t touch it. So, you know, but they can go through and they say,
You know, I just don’t like how this looks. Let’s just really
work on your,
you know, oral hygiene instructions right
now, and then when the dentist comes in, we’ll see whether or not
they agree or not, and you know, just ask questions. Yeah, I mean, I think
it’s okay, just maybe not go too far, because you want to make sure
they don’t accidentally say something that may freak out the patient,
that’s the catch.
Howard Farran: And on that note, I just want to remind all hygienists
that I’ve never met a hygienist serving time in jail for reading an
x-ray.
Shawneen Gonzalez: (Laughs) Yes that is true.
Howard Farran: Hey, Shawneen, you’re an amazing person. Thank you
for giving everyone an hour of your time in your life, and uh, it was
amazing. Thank you very much.
Shawneen Gonzalez: Well, thank you.
Howard Farran: Alright, have a great day.
Shawneen Gonzalez: You, too. Bye.
Howard Farran: Go Big Red.
Shawneen
Gonzalez: (Laughs)