Dentistry Uncensored with Howard Farran
Dentistry Uncensored with Howard Farran
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The Highest Margin Procedure in Dentistry with Dr. Dale Miles : Howard Speaks Podcast #16

The Highest Margin Procedure in Dentistry with Dr. Dale Miles : Howard Speaks Podcast #16

10/23/2014 1:59:40 PM   |   Comments: 0   |   Views: 1485

Dr. Howard Farran and Dr. Dale Miles discuss cone beam CT and X-ray risks.

Audio Podcast:
Howard Speaks Audio Podcast #16 with Dr. Dale Miles

Video Podcast:
Howard Speaks Video Podcast #16 with Dr. Dale Miles

About Dr. Dale Miles: 
Dr. Miles is an adjunct professor of oral and maxillofacial radiology at the University of Texas Dental School at San Antonio. He has also been chair of the department of oral health sciences at the University of Kentucky and graduate program director of diagnostic sciences at Indiana University. He is a diplomate of the American Board of Oral and Maxillofacial Radiology and the American Board of Oral Medicine. Dr. Miles has been named one of the “top 11 clinicians in CE” for the last 12 years by Dentistry Today. Dr. Miles has been a consultant to the Postgraduate Naval Dental School in radiology for over 15 years. Dr. Miles has a web site for teaching dentists and auxiliaries about digital imaging at, and another social network TV channel at He is in full-time practice of oral and maxillofacial radiology in Fountain Hills, Arizona. To date he has read over 17,000 CBCT scans. Dr. Miles has the best-selling atlas in cone beam CT, worldwide, called “Atlas of Cone Beam Imaging for Dental Applications” – now in its second edition.

Podcast Transcription 

Howard Farran:  It is a great honor today to be interviewing, uh, everyone’s legend in CBCT cone beam…no seriously, Dale, you’re a…Dale Miles is a, um, board-certified oral and maxillofacial radiologist, which is the American Dental Association’s, uh, ninth specialist now. Um, the only acumen I can think of for the nine specialties is Pope Poo Do…

Dale Miles:  (Laughs)

Howard Farran: …P-O-P-E-P-O-O-D-O, and periodontists, prosthodontists, oral surgeons.  But, um, Dale, I kind of think that they became a specialty because radiographs went from, uh, two-dimensional to three-dimensional. Is that a fair assessment?

Dale Miles:  Yeah, that’s , uh, that’s kind of the nutshell version. Um, what was happening is that in dental schools, and you know I’m a recovering academic, right, so in dental school…

Howard Farran:  And two, two of yours, Dale, is absolute…how many board-certified oral maxillofacial radiologists on there?

Dale Miles:  Uh, approximately 212, 215, somewhere in there.

Howard Farran:  Yeah, it’s a brand new profession. Compare that to, uh, orthodontists where there’s 10,500.

Dale Miles:  Absolutely.

Howard Farran:  And, and this is brand new, and Dale when I’m on Dental Town, when anybody’s ever talking about CBCT, they always say, Well, Dale Miles said this, or Dale Miles said that, I mean, you are absolutely known, uh, to the 180,000 townies on Dental Town as the authoritative figure in CBCT, digital imaging, but basically all things radiograph, but more importantly and more specifically, um, as they’ve gone digital. Would that be a fair assessment?

Dale Miles:  Yeah, I actually did something early on – I had a good friend who said, You need to brand yourself in, in your area of radiology, and I adopted it early, we did a lot of research in, uh, digital solid state detectors and other modalities, and so I started talking about it 1991, okay? And uh, I posted a website with all those, uh, articles on it about digital to help docs, you know, make those decisions that they needed to do. So, I, I…

Howard Farran:  And your website is very robust, uh,…

Dale Miles:  Yep.

Howard Farran: …and that’s got pretty much anything that a dentist or staff would need to know about, um, digital radiography and CBCT.

Dale Miles:  Yeah, it’s kind of transitioned…you know, cone beam is just the higher end of digital imaging, so it’s kind of transitioned. More articles are up there now on, uh, cone beam imaging that, that digital, digital tends to be in, not in the background because there’s still huge numbers of people that have to adopt, as you know, but uh, I’ve gravitated more towards the, uh, cone beam side. 

Howard Farran:  Okay, and, and…I, I like to just call it 3D radia… you know…

Dale Miles:  Sure.

Howard Farran:  …2-D to 3-D. Um, for you know, these podcasts are listened to, people from every country on earth…first of all, explain exactly what CBCT means and why they went with that name.

Dale Miles:  Yeah, thanks for asking it that way, why they went with that name, because uh…(Laughs)

Howard Farran:  (Laughs)

Dale Miles:  CBCT means cone bean computed tomography, but it really isn’t computed tomography. What you do…

Howard Farran:  What, what does computed tomography actually mean?

Dale Miles:  Well, that would be like conventional CT. You know, if you were to go to a hospital, be put on a grantry and then pushed in a millimeter or a centimeter at a time into a, you know, an imaging device, you know, great big imaging device, uh, basically that would be conventional CT, CAT scan, okay? Um, dental “cone beam CT” bears no resemblance. It’s like a panoramic on steroids really.  It’s one pass, sometimes it’s not even a full 360 degrees, and you get comparable data to look at in 2-D and 3-D. but with a minimal amount of dose. And that’s huge for dentistry. So, cone beam CT is a misnomer, really. I…

Howard Farran:  You say it’s a minimal amount of dose?

Dale Miles:  Minimal. I, and let me give you some numbers. Don’t worry about the units. If, depending on the field of view, which is the size of the area captured…okay, the head’s…the part of the head captured, it will range anywhere from as low as maybe 25 microSieverts up to possibly 125, 130 microSieverts depending on the machine, the size of the field of view, whatever. Medical CT, if I were to do a conventional, you know, CAT of your head, Howard, it would be 2,100 microSieverts, so that’s a whole order magnitude less dose. Now, the thing is we don’t get gray and white matter, and that’s a good thing. You and I can’t look at a data volume and look at, you know, the, the brain matter – that’s for a medical radiologist, so we don’t get that kind of data. We get bone, air space, some soft tissue, and it’s really, really dentally applicable.

Howard Farran:  So, so Dale, so what, what, so let’s, uh, let’s get cut right to the chase…

Dale Miles:  Sure. 

Howard Farran:  Um, now digital radiography, my goal, um, going back in the day, this is…right now, we’re at 2014, but back in the day, um, between about ’97 and the year 2000, the whole world thought of Y2K. Um, our younger viewers who were in dental school, um, who were probably in grammar school in Y2K, um, basically, um, everybody had to upgrade all their systems. So, my goal was, I’m just going to go paperless. So, we went paperless and we went to digital radiography; um, 2014, 14 years later, what percent of the dental office do you think, in the United States specifically, have gone from film to digital x-ray, for 2-D x-ray?

Dale Miles:  Okay, for 2-D, you know gray scale imaging, I think we’re still somewhere in the neighborhood of only about 55% of the, uh, of our colleagues’ adoptings, and I’ll say digital, manufacturers will include phosphor plate as a digital technology. It’s an indirect digital capture where you and I know you capture it on a plate, stick it in a scanner so it’s a little bit more time consuming, um, but if you mix those two together, about 55% adoption, so we got a long way to go, and the stuff was introduced in 1988 at the Chicago midwinter.  

Howard Farran:  Okay, So, Dale, so…okay, so let’s say that half my viewers are using film… let’s say that.

Dale Miles:  Sure.

Howard Farran:  What would you say then? What would be the reason to go digital over film?

Dale Miles:  Oh man, you got, you don’t have enough time in the program. 

Howard Farran:  (Laughs)

Dale Miles:  You know, there’s, there’s so many attributes, there’s so many good solid reasons for going, um…I’ll give you, I’ll give you a term that you use as a professional and I use, but as a radiologist I use it a little differently, and that’s ROI.  ROI for dentist means return on investment, for the manufacturer selling the product, return on investment. For me, it means that, but it also means region of interest, okay, as a radiologist, but you know, you, you cannot believe the actual…let’s say, how quickly the return on their investment happens. The dental x-ray image, no matter what flavor it is, has the highest margin of anything you do in your dental practice. I don’t know if you know that. 

Howard Farran:  Say that…repeat that again.

Dale Miles:  The dental image, the dental x-ray we’ll call it for sake of just calling it x-ray, has the highest margin of any procedure you do in your practice. I’ll give you an example. Fifteen years ago, I was in the Midwest talking about a single PA in film, start to finish - tech time, cost of chemicals, disposal, and the cost of the film, about $1.11.  The actual charge for that in the Midwest that many years ago was about $15.00, okay? Now, a single PA might be as high as $31.00, so it goes from…and even digital, it’s about $1.25, so $1.25 to $31.00? Are you kidding me? Okay, now I’m a radiologist. I’m not telling my colleagues out there to take x-rays to make money. But, we almost need imaging on every patient that walks in the office. Re-care patients, new patient exam, all the things that we see, you know, growth and development issues, impacted teeth, you name it, we need imaging information. So, when you think about it, the…and see, that’s the thing docs don’t do – they don’t think about it. It’s out of sight, out of mind, get those images bedding and they’d better be perfect. They don’t do the actual procedure. Here’s my…here’s my suggestion to your, to your followers, to the townies…go in your practice – and some of them have done this…go in your practice manager and software and query a report, and just ask your report to do nothing but the two’s, you know, the CDT codes that capture dental x-ray information, even if you don’t do them, and generate a report for six months or a year and look at the bottom line and you’ll go OMG, you know, this is amazing. And digital helps you get there a lot faster, plus the image information is instant, you can educate your patient chair-side a whole bunch better, uh, there’s no chemicals, it’s a lot greener, okay, then you know, than basically film. So, I mean, like I said, I could probably go on for another, you know, hour and a half, giving you a lecture on why you should go digital, but stuff’s on the site, they can read it there, as well.

Howard Farran:  And, and my, um, you know, I did it the most is that you, um, you know, you’re either dentist-focused or you’re patient-focused…

Dale Miles:  There you go.

Howard Farran: …and having a film an inch wide on a view box is not patient-centered or mastery. Blowing that film up on a, you know, a big monitor, and then being able to print that out and trace the nerve in a red pen and then draw a circle around the cavity that’s usually inner proximal, and let them see that it’s only this much more farther, and it’s going to go from a $250 filling to a $2,500 root canal, build-up, and crown, and you know what, we need to do this now, and you haven’t been in the office for three years, and Dale, if you leave this office without flossing cavity, the next time… because you don’t have insurance, so you don’t have insurance to help you pay for $250, you’re going to come back in pain, and now you’re going to have to give me your credit card for almost $2,500. And so, and in a profession that has to diagnose 100 cavities to treat 38, I wish they would quit always talking about how to do a filling, and start talking about the two out of three fillings they don’t even remove the decay.

Dale Miles:  Right.

Howard Farran:  And what dentists aren’t talking about the difference…the pros and cons of amalgam versus composite or self-etching or total etch – I say, You know what, I don’t care if you removed all the decay and packed it with IRM. Can we just get the patient to get the decay out? You know, they never talk about the, the uh, the cavities that were never filled. But, Dale, on the street and um, you know, I lecture a lot, a lot of dentists just say, Dale, the image on digital is not as good as film. What would you say to that dentist?

Dale Miles:  Uh, go to my website and read the digital imaging chain article. Um, Howard, here’s the deal. The technology is always out ahead of the education, okay? So, manufacturers are selling us products that look really sexy on the exhibit floor, and in our office when they show on their laptop, but it’s like, digital imaging, when you adopt it, is like a stereo system, okay? If you’ve got cheese $19 speakers and a great Bose amplifier, you’re still going to get crappy sound, correct?

Howard Farran:  Right.

Dale Miles:  So, what dentists don’t think about is that it starts with the x-ray generator. You know, how many people, when you go around and lecture or when you visit offices, how many people have an x-ray generator that’s older than 15 years?

Howard Farran:  Oh, yeah. Or they bought the practice 15 years ago from a guy that was 70, and it’s the same equipment.

Dale Miles:  Yeah, and it’s 30 years old. So, think of it this way, it’s the image that’s the generator, it has to be a contemporary one. It has to be what we call a DC generator, around 70 kV is probably ideal. Then, it’s the detector, the solid state detector, and we’ll stick to solid state, you know, a censor that goes in the mouth. The sensor, you know, basically there isn’t a bad one in the marketplace, but what they do is, you have to display it on what? A chair-side monitor. And docs buy cheap. I hate to say it, but you know, we’re quite frugal and habit-bound, you go to Best Buy and buy a, you know, $200 monitor – what goes in is what you get out. So, the frame grabber could be wrong, the, you know, the monitor could be cheese. It will show color real well. But, when you go to show gray scale images where you only get 256 shades of gray, it’s a whole different ballgame. So, you need to match your components like you do in a stereo system, and heaven forbid you want to print it out, you said something about printing it out – well, here’s the deal. I don’t know if you’ve thought about this, Howard, but color printers make gray scale images out of blue, green, and red. Are you with me?

Howard Farran:  Yes.

Dale Miles:  So, so what you want to do it you want to hunt, you want to do your due diligence, find a printer that also does gray scale. You take out the color cartridge, put in a gray and a black. Or, you add a gray scale toner. And when you ask it to do black and white, it does a beautiful image. I’d also print if people want to print, you know, to show whatever, the patient, to send it off for the endodontist, print it on a color, on a glossy paper, a photographic quality paper. Um, the image is stunning when it’s on that when you’ve matched all these components up. A lot of it’s the monitor though, Howard, is, you know, if you’re going to be making your decisions off it, you’d better have a good one that will display gray scale like bet…as good as color. 

Howard Farran:  And that’s interesting you just said that for me personally because, uh, last week, um, I just switched from a, uh, three-year-old Dell computer…

Dale Miles:  Yep.

Howard Farran: …and all my friends, well, basically my boys convinced me, they said, Dad, you’ve got to go to Mac. And so I got the MacBook Pro, and the first image…

Dale Miles:  Boom.

Howard Farran:  …I pulled up, it’s like, Oh my God, and I still had my, my um, my Dell. 

Dale Miles:  Yep.

Howard Farran:  Now, and I don’t know what the monitor is…it’s three years old, but I mean the difference in just looking at a clinical picture, I mean, it just blew my mind.

Dale Miles:  Yeah.

Howard Farran:  I mean, Apple computers…

Dale Miles:  And you’re…and you’re making clinical decisions on those images, so you don’t want…you don’t want to shoot yourself in the foot off the bat, you want the…you know, as, as much as technology as you can afford that displays it so that you and the patient can see it, but not only that, when you’re looking at x-ray information, you can actually detect the fine detail in it.

Howard Farran:  And I want to say something earlier, but you said about return on investment, I always hear, you know, accounting, um, has only been giving us three statements for the last century, and they give us a profit-and-loss statement which is for a third-party tax collector, it’s got artificial numbers, deferred taxes, depreciation, um, there’s a balance sheet, your assets equal your liabilities minus your equity or whatever, and uh, you know, that’s if you’re getting a lone or dividing assets in a divorce or something, but the main thing is a statement of cash flow, and dentists always look at these machines and say, I don’t want any debt. I don’t want any debt. And that’s just the emotional knee-jerk reaction. Well, we don’t look at the balance sheet number of the debt, we look at the statement of cash flow. So, if you’ve got a machine, let’s say your machine is a, uh, $2,000 a month lease…

Dale Miles:  Uh-huh.

Howard Farran: …but, you’re going to bill out 12 CBCTs a month, well, then who cares about a balance sheet number. Your statement of cash flow, you’re generating more cash.

Dale Miles:  Sure.

Howard Farran:  And, and Donald Trump said it the best ______, he says, I’d buy your house for a billion dollars if the terms were a dollar a month for a billion months because I can rent out your house for a thousand dollars a month. 

Dale Miles:  (Laughs) Yep.

Howard Farran:  So, he doesn’t care about balance sheet numbers…

Dale Miles:  Sure.

Howard Farran: …he cares about statement of cash flow…

Dale Miles:  Cash flow.

Howard Farran:  Yeah, it’s all about cash flow. So, Dale, you’re saying if, if the x-ray head is generating a quality x-ray and I’m picking it up on a quality sensor, and I got a quality monitor, the dentist that’s telling, um, a board-certified maxillofacial radiologist that the PA is a better image, are you saying, Dale, that he’s wrong?

Dale Miles:  They’re wrong. 

Howard Farran:  They’re wrong?

Dale Miles:  Yeah, the best film image you can get these days would basically still be in hand tanks, no one does that, you know what the quality of processing is like in a lot of dental offices after the chemicals weaken and they’re not freshened up, um, if it’s not fixed properly, you and I, over the years, Howard, because you know, I’m a little bit more seasoned than you – that means I’m older…happy birthday, by the way today.

Howard Farran:  Thanks. But, you’ve got more hair than me, so, uh…

Dale Miles:  (Laughs)

Howard Farran: …I’ll trade the eggs if I can get your hair. 

Dale Miles:  You shave it – that’s the problem.

Howard Farran:  (Laughs)

Dale Miles:  But anyway, you know, when you, when you think about it, we’ve had yellow and brown films in our cabinets, haven’t we over the years? Okay, you don’t get that. And by the way, I actually took some older, uh, film-based x-rays, put them on an optic, a digital scanner, you know, a transparency one, one that goes through the image, and captured everything, and then I discarded the color, did some image processing like we do with our tools in digital imaging, and I recovered the gray and yellow film-based crappy images quite nicely, thank you, you know, and people were amazed. They said, you’re kidding me? Here’s the original and this is what the new one looks like on my video monitor, it’s amazing.

Howard Farran:  And I, I also want to say about this technology, as far as the patient, because I’m very patient-centered, uh…

Dale Miles:  Of course.

Howard Farran:  Humans have a lot of heuristics. They have hundreds of decisions they got to make a day, easy heuristics there. Say, you want a blender, and you go to Target, and Target is amazing on, uh, blenders because they have ten, and they’re all at $10 price points. They start at 10 dollars, twenty, thirty, forty, fifty, sixty, seventy, eighty, ninety, hundred, and I’m sitting here thinking, well, I’d rather just buy the $100 one once and right, and then everyone would tell me, Oh, you got the best one. So, if you’re realistic, um, if a car costs $70,000 and another car costs $35,000, you assume the $70,000 car has twice as many bells and features and the like, and heuristics work. And one of heuristic’s worst thing with patients all over the world is that a high=tech office, they think it’s higher quality dentistry. And when they go into an office and you’ve got the yellow chart and stuffed with all these x-rays, and you’re going through all these pieces of paper, and then you go into another physician’s office and he’s got a stylette and a touchpad…like, like my physician…I, I, I mean, he’s the best one I can find in Phoenix...every…I mean, it is so amazing. My blood tests get synced into his deal, and then he tells me, Well, if you could get your blood pressure this, and he hits a button, he says, According to this study, you know, you’d live 2.2 years longer, if you did this or that or that and, I mean, and I just think the world of him. I just think he’s so smart because he’s so high-tech, and he’s telling me all these numbers, and then it’s all the…emailed to me, and I mean, so, going high-tech…Okay, so the bigger decision, Dale – you said 50% have digital x-rays…what percent of the dentists have a CBCT or a 3D x-ray machine?

Dale Miles:  I knew you were going to get to cone beam eventually, but…just kidding. Um, cone bean adoption has been actually more rapid than digital, believe it or not, digital solid state sensor now. I’ll say more rapid because, um, you don’t have to own a cone beam machine to actually use the data from it. So, more dentists are actually ordering, you know, a scan or sending to a patient to have a scan, getting the data back to put in software to do implant planning or obstructive sleep apnea or whatever. I don’t know the numbers, um, all I know is that the interest and the adoption is going more rapidly than it did for solid state detectors that go in your mouth, um, many more applications. I mean, what do solid state intraoral detectors do? Cavities, bone levels, PAs, you know, to look at the root, apex. This cone beam digital imaging is really, it’s on steroids. We see so much more information. Problem being, we see information in three anatomic planes of sections – sagittal going side to side, coronal going front to back, and then the traditional CAT scan axial going from head to toe where they push you in a gantry. Don’t do that with cone beam, it’s one pass and you’ve got all the data to look at in 3D and/or in all those planes of section. So, there’s a learning curve, and that’s one of the stumbling blocks. You know, you asked me about adoption, the sort of, you know, the breaks go on a little bit because docs do two things…our colleagues say, when they buy it, they go, These are great, what am I looking at, so they want more information and manufacturers can’t provide that, so we have to put on programs. Number two, basically when, uh, before they purchase, they go, I’m so afraid of missing something because there’s so much more data there, I can’t buy it at this point. So they talk themselves out of it. Um, we’ve got to get them past that hump, and when we do, when they see the applications – endodontics, implant, TMJ, paranasal sinus evaluation, obstructive sleep apnea, uh, the list goes on, okay? They get better data to make better decisions. Where’s the downside of that? Patient, patients love it, they see better, docs love it, there’s less morbidity for the place for the implant, uh, so there is no down side. You know, everybody looks again at cost. Well, the cost again, is recovered so rapidly and the data is much better to make clinical decisions with, there’s no down side. 

Howard Farran:  You know, I was reading an article on your website, um, and uh, it made me think that, um, we should say that the TMJ centers in America are on the Stevie Wonder/Ray Charles system because you, you showed it…because a lot of these people, every TMJ patient’s the same: they need a stent, they need a bite, they need a ______, you know, it’s just…they just…and then you showed a CBCT with clear-as-a-bell, a particle, I don’t know what it was, if it is was bone or cart…whatever, in the joint site. You know article I’m talking about on your website?

Dale Miles:  Yeah, it’s called a loose body up there that…

Howard Farran:  Yeah.

Dale Miles: …it happens in hips, happens elsewhere, yeah.

Howard Farran:  Yeah, so how can you be treating TMJ if you don’t even know if they have a loose particle floating in their joint socket, and um, by the way, what did that person need? I mean, did someone need to go in and retrieve that or was that a surgery or…?

Dale Miles:  You know, it depends, Howard. Again, uh, what I do in my, in my specialty is I keep my dental colleagues out of trouble. Do you know John Flucke, you’ve read some of his stuff. John calls that…

Howard Farran:  I was, we were classmates and I was Farran, F-A-R-R-A-N, and he was Flucke, so we sat by each other in every lab in class for four years. He’s a great a guy.

Dale Miles:  Yeah, well he calls me his Get-out-of-jail-free card with cone beam because I look for the stuff that, that most dentists are not looking for. Now, having said that, if I report a loose body in the temporomandibular joint complex area, it might not be symptomatic enough for someone to go after, but it might be the reason they have the intermittent locking and the pain, and it can all go away with a simple surgery, not a big open-flap thing on the joints. Nobody does that any more. But, just as you know, trephination procedure, tweak it out, steroid lavage and bingo, you know, patient doesn’t have that problem anymore.  Um, so yes, the decisions…to visualize pathology, to visualize anatomy, in 3D color, you know, when you need to, it’s amazing. Let me, let me just add one. What’d you learn in school on how to localize a supernumerary or some, some abnormality in the jaws? You learned Buccal Object rule or Clark’s Rule, or in some cases SLOB rule, same on lingual, opposite on buccal.  That all goes away. You just do the cone beam, rotate, look at it, see it in 3D, make an instant clinical decision.

Howard Farran:  Okay, but, but in all fairness to our viewers, you’re…I’m going to have to back you up and explain that because the biggest complaint when I’m lecturing in, uh, Africa, Asia and South America, they don’t have the money for CAD-CAM, CBCT, so go back to those three rules for our viewers in, uh, in parts of the world where they don’t have that money for that type…go, go through those three rules.

Dale Miles:  Um…

Howard Farran:  Slob. Go with SLOB.

Dale Miles:  Yeah, SLOB means same on lingual, opposite on buccal. So, basically if you saw, let’s say a supernumerary tooth, you know, uh, an extra bicuspid in the mandible, and you and I know that, you know, we did tube shift or Clark’s Rule, we’re all taught that, or if we move our tube head, you know, uh, in one direction and the object in there moves in the opposite direction, same on lingual, opposite on buccal. That’s a very simple way of learning that, okay, or remembering that. If your tube goes posterior and the object went posterior, it’s on the same side, same on, you know, same on lingual, opposite on buccal. So, those are the things that, that, they really go away. And when you say that, that around the world – and I get this because, you know, I’ve lectured not as extensively as you have, but probably in at least 29 countries, and you don’t have to own cone beam to use it. So, there could be a specialty clinic, there could be a hospital. If they’re educated to what we can do with cone beam, there could be a centralized, you know, imaging area and then data goes back to the doc and all they’re doing is image processing like they’re doing with some other digital technology. So…

Howard Farran:  And then, for the record…

Dale Miles:  Yeah.

Howard Farran: …explain Clark’s Rule. 

Dale Miles:  I wish I could. I don’t remember Clark’s Rule.

Howard Farran: Too old, too. Okay, SLOBs good enough.

Dale Miles:  SLOB is the good one.

Howard Farran:  And I wanted…I wanted to ask you another thing that dentists are always asking on Dental Town. Um…

Dale Miles:  Sure.

Howard Farran:  There are rumors out there, um, that come from the, um, the…what was the old Sony camcorder…

Dale Miles:  Yeah.

Howard Farran:  That, there was only one factory on planet Earth that made a camcorder, and everybody’s name that you saw was, um, one factory made it and then slapped all these names on there. And a lot of people are saying that in dentistry, that a lot of these sensors are basically made by just a few original equipment manufacturers. Is that true? Is each brand you see, do they actually make all their sensors and that or are these just, uh, um, the same piece of equipment…I’m talking about sensors, and just…

Dale Miles:  OEM’ing, yeah.

Howard Farran:  Yeah, OEM’ing.

Dale Miles:  There are many, there are four or five real major chip manufacturers located that supply that, but in terms of how you put it together, um, many companies make their own – I won’t say they all do because, uh, some of them rebrand, you know, they buy it here and then rebrand it and put it in with their package, so I couldn’t tell you how many there are, but um, let’s say there are 20 solid state detector products out there. I would say that probably closer to half are made by that company. Okay, by its own company, but um, that early on, their comment was probably more true, that there were only three or four, you know, major, um, people that put it together, based on the specs that were requested from the company. We want rounded corners; no we don’t care, we want square corners; we want our, our connector on the back; no, we want it on the bottom; we want it on the corner, okay? So, um, I don’t think you have to worry about that now. To me, that’s like a red herring from what you’re hearing from our colleagues. Who cares who makes it? If it makes you a better dentist and makes the patient, you know…decision-making…

Howard Farran:  Well, be specific. Are there, are there certain brands that you recommend that you think are better or do you want to stay away from that for political reasons or…?

Dale Miles:  Yeah, you know, I always stay away from it because, um, what I do tell people is do you like your, your, the person in your office that distributes to you, okay? Do you like your rep? Do you like the company that rep works for? If you do, it’s often better to stay in the family because product support becomes, uh, less of an issue, okay? But, I also, on the other side of the coin, don’t like, Well, you have to buy our sensor because it’s with our software and they won’t work together. There’s a lot of that that gets put out there. I’ll give you an example. At the Arizona School of Dentistry and Oral Health, when I was there are the Dean of Clinical Affairs, we put in, um, we put in an enterprise software because we had a big clinic, 100+ users. We knew we were going to have remote clinics so we wanted to be able to share that information remotely. So, we had, before I got there, Sullivan Shine was the supply comp…partner, um, we put in Dentrix Enterprise, and I’m just throwing these out because this is what we did – I’m not selling this on, on, on your show. Um, when it came to the equipment side, what x-ray stuff are we going to put in? I actually said to Dr. Dillenberg, the dean, I said, We’re going to put in Planmeca. He went, Well, that’s not Shine, and I said, I know it’s not, but I’ve had it in four schools, this stuff works, I’d like that.  I’m the radiologist, as well, so this is what I want. How are we going to make it work? TWAIN drivers. So, the first image we took…by the way, the first day we opened our clinic, guess how many emergency patients in addition to the ones appointed we had? We had 50 people standing at the door, day one, okay, with emergencies. And one of the local oral surgeons who were on our staff comes running down, he says, Where’d you get that panorex? I said, The one over there on the screen, and he’s looking at the dig…That is so much better than my film. I said, I know, Saba, but I said, Aren’t you impressed that she’s still putting on her earrings and you already saw it upstairs? And he was, Oh my God, I never thought of that. So, I mean, yeah, I’m a little bit off topic with that, but we put in, um, a different type of equipment, it didn’t matter because with the way they can communicate together, it captured, came up in Dentrix and on our screen immediately. So, not a problem.

Howard Farran:  I, I want to say that when I was lecturing in Helsinki, Finland, uh, I went to the Planmeca headquarters and oh my God, what a class act. 

Dale Miles:  Pretty awesome.

Howard Farran:  There in Scandinavia, it’s got some amazing companies, it’s just amazing. So, so, let, so, I’m going to, um,             we’re at half time, 30 minutes down, 30 minutes to go – so Dale, um, you said about half had digital radiography, um, what are you thinking about CBCT…it hit a percent, do think it’s at 5%, do you have any idea…

Dale Miles:  No, I really don’t.  The manufacturer…and people ask me that question, but the manufacturers don’t share their data at all, and so I can tell you the, when you sort out the players, okay, the actual companies, I can tell you that, uh…

Howard Farran:  Let’s go through the…let’s go through the players.

Dale Miles:  I knew you’d want to know that.

Howard Farran:  I want to go through the players, and I also want to tell you that, um, a big dilemma everybody’s having – it’s easy if you’re an endodontist and you know you just want a small fill, you just work on one tooth. You’d know if you are an orthodontist and you just want this large drill.  A general dentist is kind of stuck between a rock and a hard place because he does endo and he might do ortho. So, so let’s, let’s go through the major players, and then also tell them the pros and cons of, uh, do you want to talk about…well, first, let’s…why don’t you talk, explain about the different needs of an endodontist working on a molar, looking for missing anatomy versus an orthodontist who’s looking at all the teeth.

Dale Miles:  Sure, and you know, what’s happened in the industry which is a good thing is that, um, from user feedback of the bleeding edge, you know, the first users, basically it became very apparent to most manufacturers that they couldn’t just have a small field of view or a large, okay, that they’re at war something in between, that they had to be able to collimate or change that field of view so you’re seeing a lot of product come out now that has a lot more capability. I mean, you can push a gooey, the graphic interface, user interface on the key pad, and select an area that you want. So, um, you know, an endodontist has different needs obviously. They have only small volume needs, three products out there – Carestream, uh has one, um, J. Morita has one, Planmeca has one, uh, and I may be missing somebody, but those three, um all make, uh, smaller field of view capture units that…

Howard Farran:  That was Carestream, J. Morita, and Planmeca?

Dale Miles:  Yeah, they all…

Howard Farran:  They make a…go ahead.

Dale Miles:  They all make a, you know, a machine that, with actually quite a small field of view, and even a couple of those you don’t, you can’t make them any bigger, okay?

Howard Farran:  Now, let me, and let me just interrupt you one thing on this small field of view – um, when you talk to elite research endodontists, they will tell you that the number one cause of a root canal failure is, uh, too u much preparation. You know, you flair out the canal… you substantially weaken the tooth. But, number two they will all tell you is missed canals… 

Dale Miles:  MB-2s.

Howard Farran:  MB-2s on maxillary molars, um, buccal canals on the distal of a, uh, first and second molars, and lingual canals on mandibular incisors, and they will tell you that they’re just routinely missed and, um, to be able to see your molar before you walk in there and say, Oh, that’s clearly got this many canals and, and, just knowing that when you walk in there, so this is, this is very important for endodontics.

Dale Miles:  Yeah, it’s huge, and actually, uh, myself and Marty Levin, okay, who is an endodontist, I’m the radiologist, um, what we’ve done is the AAOMR, my group, the radiology group, has approached all the other specialties and we’re putting out joint physician papers on the use of..., you know, cone beam CT or cone beam volumetric imaging probably a better term, um, and, and…

Howard Farran:  What did you like more than CBCT? What did you like?

Dale Miles:  Well, that’s a moot, it’s a moot point when…in my first text book that’s sold out, it wasn’t called cone beam CT, it was called cone beam volumetric imaging, and the reason I did that was because it isn’t CT, okay?  And again, there’s no resemblance in terms of the way you capture, just the end product looks kind of similar, to um, but I was knocked down by a number of colleagues and others that said unfortunately, where cone beam CT got into the literature early if you search, you know, uh, you do a search engine or you go to Pub Net or whatever, and you type in cone beam volumetric imaging, you’re going to get nine papers, but if you type in CBCT, you’re going to get, you know, 2,0009 papers, so I had to acquiesce in the second edition and, uh, I’ll send you a, a still image that you can put into the polished, finished product of this, uh podcast and you’ll be able to see the, the book. But, um, um, and I forgot what we were talking about now…the cone beam, uh, oh, endodontics.

Howard Farran:  Yeah, endodontics.

Dale Miles:  So, we, we were the first group done.  Marty and I were the co-chairs, Marty Levin and myself, and we had wonderful, uh, people on our committees that did really, really hard work, and we published in AAE and on our site, the website for the AAOMR, we published the guidelines for the use of cone beam in endodontic, and then came along, they’re doing TMG, there was one for implant, they’re doing it for third molar extraction, there’s going to be, uh, position papers on all of those that, that eventually work their way into our, our offices and our literature. Okay, so endodontics, it’s a given. I mean, I truly believe…and by the way, endodontists now, um, you know Howard, endodontists have failures, and you know why? Because we send them all our crappy cases, okay? You know, so what are they going to do? They’re going to retreat or are they going to, you know, take that offending tooth out and maybe do an implant. So, endodontists are really, seriously interested in actually doing the surgical piece for the implant, still goes back to the general dentist to restore as always, okay? And they work through sculps, they’re surgically oriented, you know, so I don’t see that as a bad thing, I see that as a good thing.

Howard Farran:  And endodontists also say that um, a lot of dentists who do their own endo will see a failure, and will spend an hour and a half appointment doing a retreat, whereas if you had a CBCT, you’d find out either A – it was a missed canal, or B – you also see root fractures on these. 

Dale Miles:  Yep. And then, and then now you go to an implant rather than try and beat your head against a wall retreating the tooth.

Howard Farran:  And also, it’s patient-centered because, um, endodontists will tell me this, and tell me if you believe or if you agree with others – saying that a standard x-ray, a two-dimensional x-ray, a PA, is not going to see a ______ lucency until at least twice as large as what you would see on a CBCT. So, if you had a CBCT, you’d say, oh Dale, there’s a ______ #3 and then you’d test and it’s not vital, you say, Okay, let’s do endo now, and it’s totally asymptomatic, whereas a two-day picture you wouldn’t pick that up, and then Dale comes back, calls you eight months later, and it’s exploded and he’s in pain, and now you have a more difficult treatment. Its like in one step, an asymptomatic tooth, but you might not want a one-step, you know, as asymptomatic goes…

Dale Miles:  Right.

Howard Farran:  So, is that true? Can I see a ______ lucency smaller earlier than on a 2D…?

Dale Miles:  Absolutely, and here’s the deal. You and your endodontic colleagues and our colleagues that still do their own endodontic procedures, um, they basically are using it to assess it at the front end. As a radiologist, I’m looking at a volume of data, large or small, the amount of residual apical periodontitis or the lucencies that I see is just astounding, okay? So, I’m the validation at the back end. I wondered why that tooth was acting up. Well, here it is, you know?  There’s a, a lucency in three anatomic places of section, and remember, our ______...

Howard Farran:  Are you talking about after treatment, significantly after treatment?

Dale Miles:  Oh yeah, I see so much residual perioapical lucency that the endodontic community that I know, both here in North America and over at, you know, worldwide basically, are saying our success rates are going to go down now. And I said why? They said, Because we have tools where we can see; you know, one of their criteria was no residual radiolucent area. Well, guess what? There’s a whole bunch of them. 

Howard Farran:  And you’re also seeing a retreat from the one-step, aren’t you, where…

Dale Miles:  Yeah.

Howard Farran: …everybody was just one-stepping _______ saying, Ah, you can do it all in one appointment. And now you’re finding like, well, maybe not. Maybe you should put some inner canal medication in there and, uh, get rid of all that infection first.

Dale Miles:  Yeah, and the other thing I’m seeing is that, you know, when you look at the number of steps involved to retreat versus, you know, okay, I give up, this tooth beat me, uh, we’re going to take it out and put an implant in, I’m seeing a little transition to that tremendously because predictable, you know, implants are more predictable. Um, and think about an endodontic office – what’s a typical unit of time? It’s about ten minutes. And who wants to be having someone file their canal for an hour and a half? You don’t want that. So, endodontists do it quickly, they do it efficiently. Um, if they have to retreat something and take six units of time, you know, over a retreatment when they could have just extracted, put an immediate implant in and then send it back to the doc so that when it healed, they could restore it, that’s a…that’s a much better scenario for the patient.

Howard Farran:  And I want, I want to say something else. Um, there’s um, the fastest growing segment of the population, you and I know, live in Arizona is, uh, senior citizens, and the fastest…

Dale Miles:  Who you calling a senior citizen, buddy?

Howard Farran:  All the people in our backyard between your house and mine. Um, fastest growing segment of the U.S. population, percent wise, is 100-110, the second fastest is 90-100, third fastest is 80-90, and Dale, women are living five years longer than men, and one thing that I don’t see anybody talking about, which is the 4,000 pound elephant in the room, is that I’ve been out here 27 years, there’s a dozen nursing homes within a, you know, in my zip code, and I have to go there and see them, and that lady that, um, got the, um, four implants are four on the floor, she’s sitting there at the table playing bridge and eating anything she wants, and when they start getting rheumatism or dementia or Alzheimer’s, they’re just wiped out by root-surface decay in literally, I, I would say in under, I’d say between 12 to 18 months, her 75 years of dentistry, it’s just in the trash can, and we just don’t talk enough about biology. I mean, when you’ve got a titanium implant that cannot be eaten by streptococcus mutans, and a lot of people are saying when they get admitted, they get ______, not the periodontal disease you see around a tooth, I mean, you might get some inflammation, some ______ budding, but you don’t have the full-fledged periodontal, and if you don’t believe me, what happens to a full mouth of perio when you distract all the teeth? It’s all gone, right?

Dale Miles:  Yeah.

Howard Farran:  And uh, so, and I, you know, when I go to those nursing homes, Dale, there’s no one in there that looks like me and you – it’s all women. And you know, I think the average white male in America is 74 years of age, _____ the average female is almost at 80, and you go into these nursing homes, there’s 100 women and one man named Lucky, and uh…

Dale Miles:  (Laughs)

Howard Farran:  …I, uh, I don’t even know if I want to do molar endo on a 65…er, for me, at 65 years old, I’m sitting here thinking, and then I talk to an insurance actuary – he said the best rule of thumb to predict a patient’s age, if you don’t want to be an actuary and ask a thousand other questions, is a male and a female in America is most likely going to live like a year and two months longer than their dad or mom. I mean, just the bean average. So, when you’re looking at a 65-year-old lady and she needs a root canal, and you say, How old was your mother when she passed away, and in Phoenix, half the time they say, my mother- she’s still alive, and I’m like, Oh my God, oh my God, should I really be putting a tooth in here? So, um, so you talked about, um…oh, and I want to say one more thing ______ for all the, uh, what you just said, is dentists always schedule a six-month recall for a cleaning, but when you do a, you know…four out of five…the average dental office has 5,000 charts and 1,000 are active, and 4,000 have just fallen off the charts or what have you, what have you, but you know what – when you do a root canal, you schedule a one-year followup, um, to, you know, they say, hey, you just put a thousand dollars and I want to see it a year later to make sure it all healed up and we don’t have to do anything, and then what that does is, the only definition of an active patient is someone is scheduled for an appointment, now I know Dale just walked out the door, but at least I got him scheduled to come back sometime, even if just for a PA or a CBCT of, uh, of that root canal, so that’s good. So, we talked about um, small vision, um, and then orthodontists want large vision – let’s go through the companies, Dale. We’re 45 minutes into this – for the last 15 minutes, go through these name brands because dentists want action plans and they don’t want to, um, I’d like you to listen to this and say, they’ll say, I’m going to need a CBC, give names, give companies’ names and let’s walk through this.

Dale Miles:  Sure. Yeah, I’ll do it like I lecture, okay? Because, you know, I am a general dentist, I did it for up until ’99, you know, private practice seven years, a bunch of years in school one day a week.  When radiology became a specialty, of course, I narrowed it to my specialty, but I think like you, okay? I was one of you, all the way up until ’99. So, general dentists don’t necessarily want a small field of view because that limits them. Some of them don’t want a large field of view because they’re worried about the information in the scan. So, what’s in between? I always tell them, look, you’ve got machines that will do a dental ______ volume, 8x8, okay, uh, 8x8 cm, centimeters, and that for most purposes will suffice. But, you also have to think about multifunctional machine. What do I mean by that? I mean, you’re not going to do a cone beam on everybody just because you own the machine, no matter how quickly that helps you recover your ROI because you have to sit down, examine the patient, determine the need, it’s just another tool, okay, cone beam. What if you have a machine that does a panoramic, digital panoramic, extraoral bite wings, okay, or bitewing appearing – by the way, they’re not just bitewings. When you look at them, you see the periapicies from the canine back, it’s like, oh my God, I’ve narrowed this down to about six images I have to put in the mouth. So, the deal is you want to look at companies that make these “multifunctional machines” – I hope I didn’t miss anybody. I didn’t prepare and make a list or whatever, but you’ve got Carestream, you’ve got Instrumentarium, you’ve got Planmeca, you’ve got Gendex, okay, you’ve got VaTech, you’ve got, uh, well, ______, they don’t make the, they don’t re-label the VaTech machine anymore, so it’s gone, um, I’m probably missing somebody…oh, Instrumentarium now, the imaging sciences have, uh, a flex or one of those machines that actually allows you to make a smaller field of view. Now, you have to do your due diligence. You have to look at the machines and say, which ones do all of the things that I said? You know, and which ones do them well? But, if I were a doc, I’d think of one that does more than just cone beam, it does cone beam when you need it, but really does the bread and butter sort of imaging of a digital pan, a high-quality digital pan which you can make a lot of decisions on. And let’s give you a for instance – we’re going to maybe do another, you know, podcast down the road on dose on how to talk to your patients about dose – intraoral rad optic cone beam. But, say you’ve got a nine-year-old, and the manufacturers said, well, doc, you, you can do all your imaging with cone beam, you can get a panoramic out of the cone beam. Well, yeah, you can. But, as low as the dose is, it’s still higher than a digital pan. So, if you get a nine-year-old and all you are assessing is are the successor teeth there in the right locations, you cannot justify doing a cone beam on that child, okay, just to get the pan, when a pan would be 5-10 microSieverts, you know, versus 100 microSieverts. Not justifiable. So, just because you own a machine, a cone beam machine, doesn’t mean everybody gets one.

Howard Farran:  And I, let me, let me…

Dale Miles:  Wait a minute, get one that actually that’s multifunctional, then it also helps pay for the cone beam portion.

Howard Farran:  And Dale, what are…when you go from a 5-10 to a 125 units of radiation, are you still mostly concerned about the thyroid and, does a thyroid collar play into this, or is there other things that you’re worried about?

Dale Miles:  That’s a…that’s…

Howard Farran:  Is thyroid…

Dale Miles:  That’s a whole other…that’s a whole other podcast, but yes, um, on children, the, the NCRP guidelines adopted by the ADA and FDA say that every child gets a thyroid collar unless it interferes with the examination. Well, guess what? On a panoramic or a cone beam, it comes off because it does interfere with the examination. It will put artifact in areas you’re trying to interpret. So, there are a lot of changes to guidelines which dentists, they’ve been published for a lot of years, but dentists have…they’re guidelines, they’re not rules, they’re not mandated. So, we can talk about that another podcast because I’ve got lots of information to help people about that. But, you know, cone beam for the most part is…let’s say you were an implant doc – that’s what your main part of your practice was. The ones that have been doing it for a long time would say, Well, I use CAT scans because it’s more accurate information. There’s no justification now that cone beam’s here for doing a CAT scan in a hospital unless you live in Podunk somewhere and the only access you have to any 3D imaging is in a hospital with a scanner. Cone beam, being such a low-dose procedure, should be, you know….got to get, be careful about standard of care, but it should be the only modality that somebody uses to assess an implant site and do their planning, okay?  Dose, you know, all about the dose. 

Howard Farran:  So, so, um…

Dale Miles:  I don’t…

Howard Farran:  Go ahead, go ahead, keep going.

Dale Miles:  Well, I laid out the manufacturers sort of by name…I think what they have to do is look at those that will do multifunction and it will fit better in their practice, okay? 

Howard Farran:  So then, I’ll ask you another question, um…

Dale Miles:  Yeah.

Howard Farran:  Market share. Um, a lot of dentists don’t care in who wins the People’s Choice Award on a song or whatever because that’s all artsy fartsy, but market share becomes very important to dentistry because everybody voting with their dollars or voting in the Townie Choice Awards, everybody voting has got 8-12 years of college, dentists are notorious for amount paralysis from overanalysis, they make decisions very slow, and when they do make a decision, they make a lot of good decisions. I mean, these are smart boys and girls that know math, physics, chemistry, biology, um, who are they mainly behind? 

Dale Miles:  You know, it…that’s an interesting point. Um, I think the, the largest number of units is probab…worldwide is probably imaging science I-CAT, um…

Howard Farran:  I-CAT.

Dale Miles:  Yeah, they were to the party early, um, they had a machine that, um, that was less expensive than some of the earlier versions out there, it was one of the first sit-down machines, okay? There are some limitations with some of it though. Um, it has an aluminum arm that comes around you are some larger patients can’t get in there, okay? Um, on that aluminum arm is a chin, is a bite pin. Well, if you’re on a bite pin, there still could be some movement. Well, movement kills a scan, so even though it is a high seller, I haven’t seen…I haven’t seen enough improvement for stabilization of the head and things that will affect the scan. Having said that, I see good quality scans from people that pay attention to gathering them. Planmeca’s big, Carestream’s big, um, uh, VaTech makes an inroads, but I’m, I’m not as convinced that they support the product the way that the others do, okay? Um…

Howard Farran:  Where is VaTech out of?

Dale Miles:  Uh, they’re out of Korea. 

Howard Farran:  Korea.

Dale Miles:  Okay, they have offices here in the U.S. as well, and they have a lot of ______ sales force…

Howard Farran:  You’re seeing customer service issues with them?

Dale Miles:  I’m not seeing them, I’m hearing about them, you know, from you know, uh…everybody, every company has issues, but you know, I’m, I’m, I heard more from that particular, uh, product. Um, Gendex is basically a version of I-CAD. I don’t know if you knew that or not. So is the cable machine which isn’t sold here, it’s sold in Europe, um…

Howard Farran:  Is that, is that because um, they’re all owned by that big holding company out…what’s they name…Danaher?

Dale Miles:  Danaher, yes.

Howard Farran:  So Danaher owns all these players or…

Dale Miles:  Right.

Howard Farran: …and since they’re all owned by one guy, are they integrating them in different ways or…

Dale Miles:  Uh.

Howard Farran: …hard to say.

Dale Miles:  Good question. I don’t know. I don’t know. By the way, one of the companies that I missed was J. Morita on those multifunctional machines, and you should put that one on your list because, uh, it’s been my experience, and things change, you know, as, you know, look at Samsung and the success of Samsung out of Korea, that’s a huge company that makes lots of ______ on the consumer side and makes great products, but I always used to say, and I still am of the belief that, um, companies in Finland or Japan make the best x-ray equipment in the world, okay?

Howard Farran:  Finland…and Finland being um, Helsinki, Finland, Planmeca, ______...

Dale Miles:  And also…and Instrumentarium, as well. 

Howard Farran:  And Instrumentarium.

Dale Miles:  Yep. Yeah, that doesn’t mean I’m dissing the rest. What that says is that they were early to the party with panoramics, so they have been able to grow and develop, you know, their products much longer than some of the other players out there. So…

Howard Farran:  Yeah? So, uh, um, yeah, and by the way, when you lecture in, uh, Korea, when you lecture in Asia, I think it’s so funny in China, um, and you’re dressing really fancy.  A compliment in China’s a, Oh, you’re looking Korean…

Dale Miles:  (Laughs)

Howard Farran:  …because they, uh…what are the three big brands? Samsung, Hyundai, what’s the other one with the happy face, um…? I always forget that one. 

Dale Miles:  Life…LG?

Howard Farran:  LG, um which Americans say stand for Life is Good, but it’s not really, not exactly the correct, uh, correct translation, but, uh, yeah, this ______ in technology. So, Dale, I got your for five more minutes. Um, what I want you to do, for the last five minutes, is the big close to a dentist that’s sitting there, and I’m going to set this question like, don’t look at the balance sheet number, if you took ten of these a month, you’re going to pay your monthly payment, so let’s take money out of the equation because it is…it might make your balance sheet number look ugly, but I guarantee you everybody I know increases their statement of cash flow and their cash flow, so let’s take money off the table. We have five minutes to close this thing up. Why should I really buy a CBCT? Isn’t this kind of a big decision? 

Dale Miles:  It’s a huge decision, but it’s going to make you a better doc, it crosses a lot of the disciplines, you know, the things that we do in dentistry so that you’re not restricted, you know, to, hey, I only do cosmetic or whatever. It goes across the board for a lot of things that dentists want to do. Makes you a better diagnostician. Um, if you have the data in order…you know, those points to make decisions about the treatment that’s most appropriate for your patient, there isn’t a better imaging modality. I do want to caution people though. I know you said money’s off the table.  Remember, you still have to examine the patient for every radiographic procedure and determine the need. So, although you say, 10 a month and it will pay for it, the goal is not to do 10 or to do 15 to increase your bottom line. The goal is really to treat your patient better, which is what you’re all about. So, um, I don’t think there’s a better modality. I think they’ll continue to make improvements. You may see pricing come down a little bit, but I don’t think pricing should be as a huge a decision point for you once you look at the applications and all the things you can do for it. One thing I will do though. I’ll caution everybody – um, you can’t learn this vicariously, you can’t learn it in a short period of time. There is a learning curve with it, not just what the manufacturer teaches you, but um, you have to revisit anatomy, you have to…you’re going to be looking at areas you’re not used to with, what they call, a cult pathology, pathology you weren’t anticipating that I see. I’ve read over 17,000 scans now off all the different machines, and I find something in every other scan to report, and probably every fifth scan, to refer. 

Howard Farran:  Now Dale, I, um, now for me personally, um, I upload ours into a Dropbox…actually, to be honest, my assistant, Pam, does it…but, um, but tell them how they, they want you… you’ve read 17,000 scans, you’re the top in your field, um, I take the film and then there’s a button and it goes to a Dropbox. Tell them how I send it to you, and there are listeners around the world – how can they send you a scan to read a scan? Do tell.

Dale Miles:  Right, I don’t use Dropbox. I have had patients, you know, clients rather send me Dropbox or Hightail or one of those products, okay, and they’re encrypted and for the most part, pretty darn secure, okay? But, I have a server in my home, I give, I assign a User ID and password that only you can get in and only you can see your file folder. The DICOM data, uh, is exported from your machine. The, the image data is in what we call a DICOM format, digital imaging communication and medicine format. It has to be in that format because not only the image information, but a lot of the things about what, what body part, what was the kV, what, is this the first time they were imaged travels with that. Once it goes up into my server, I get them to send me an email that says patient name and date of birth, that’s it. That’s all I want to know. I don’t want to know anything else unless there is something real specific, um, because I don’t want a lot of data going around the internet that could be in violation of HIPAA if someone got a hold of it. So then I put it in third-party software. I can‘t afford everybody’s software from all the different machines, so I read in a third party, very robust software called Cybermed On-Demand 3D, On-demand 3D, great software, and once I do the…I capture images like screen shots of the interesting things, I put it in a report. The report is, and I can talk to you about that at some other podcast, but um, the report is then put in a PDF file up back in their folder that only they can access, they drag it down, um, basically then put it in their patient’s chart or print it or refer when necessary. 

Howard Farran:  And, and, um, what I love about my podcasts is um, you know, the, the dentists are usually multitasking when they’re listening to a podcast, they’re…they’re mowing the yard, they’re riding their bike, they’re vacuuming, doing laundry, um, will you email me, um, whatever you email me will be following a transcription because I don’t want some dentist right now parking his bicycle to try to get the notes for what you’re saying, but um, I wish you would email me the exact instructions on how my listeners can send you a CBCT and, uh, and start this process. 

Dale Miles:  Sure, um, and I want to do one last thing, Howard. I don’t know if you can see this or not, but I want to hold this up. 

Howard Farran:  (Laughs) Happy birthday from the two most ______ around the world. Oh, that is awesome. 

Dale Miles:  To the third.

Howard Farran:  Oh, well Dale, um, for those of you who don’t know Dale, um, or, um, we both…I live in Phoenix because I’m poor, and you live in Scottsdale because you’re rich, but uh, um…

Dale Miles:  Fountain Hills.

Howard Farran:  Oh, you’re not in Scottsdale, so you’re in Fountain Hills. And by the way, Dale, I have to ask this, but, uh, sometimes you sound like you have a Canadian accent…

Dale Miles:  Oh yes.

Howard Farran: …so explain that to the viewers.

Dale Miles:  Well, I’m a Camerican. I’m a Canadian-born, American-naturalized, Frankfurt, Kentucky in 1999.  I can talk like this and do the interview if you want me to. But, uh, I have spent 32-1/2 years in each country and I love them both. So, that’s why you hear the Outtenhausen about. 

Howard Farran:  So, just to be clear, you have multiple, uh, um, accents, and you can lecture in any format, so when you’re in Kentucky, you can turn on the Kentucky…

Dale Miles:  Absolutely. We’ll go do the _____ in New York, you and me, okay? (Laughs)

Howard Farran:  But, uh, you’re a legend in the field, Dale. Thank you so much, and you have a course on Dental Town, too, and online, uh, CE course on Dental Town…

Dale Miles:  We’re, we’re working towards putting more courses out there for ya, as well, so yes, and I appreciate the, the opportunity to do the…this is my first podcast with you, so…

Howard Farran:  Oh wow. And Dale, seriously, thank you, not only for everything you do for dentistry, but everything you’ve done for Dental Town. You’re a great neighbor, a great friend, and the students, um, when I lecture in the dental school, I bet they li…I think you’re the favorite lecturer over there, I mean, seriously, I mean…like Aaron Harris, those guys love you. They worship you. You’re a great guy. Thanks so much for giving me an hour, on my birthday.

Dale Miles:  There you go, happy birthday.

Howard Farran:  Already buddy, bye-bye.

Dale Miles:  Thanks Howard. Bye.

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