Interpreting Advanced Imaging: It’s Best to Know Nothing

by John Khademi, D.D.S, M.S.

Interpreting advanced imaging, such as CBCT imaging, is tricky. Evidence of just how tricky becomes apparent during lectures I give on the subject. I will show a study to the audience and discuss it for several minutes. When I take it down, I ask them which side was buccal? Which side was palatal? Was it tooth number 14 or number 3?

The audience will start guessing, because they really don’t know—even after looking at the tooth for 5-10 minutes. They would never mistake buccal for palatal, or the tooth numbers, with 2D radiography. But with 3D radiography, it happens all too often. I’ve been evaluating 3D imaging everyday in my endodontic practice for eight years now, and I can still make this kind of mistake. The issue is this: we don’t have that same set of skills with 3D radiography that we do with 2D radiography, but we think we do.

In medical radiology, however, they’re well aware of the complexities that go along with interpreting imaging. That’s why medical radiology is a four-year specialty after medical school—with sub-specialties after that. You don’t want a mammographer evaluating the CT of your head or a thoracic radiologist reading your mammogram.

The need for specialization is clear: interpreting 3D imaging calls for a well-trained eye. That’s why we have to be very careful when we interpret with CBCT. For this reason, I’ve developed a strategy for interpreting 3D imaging based on what has been learning in medical radiology.

It’s important to note that I don’t automatically order an imaging on every patient. Whenever possible, my staff provides me with the minimum information necessary to determine if an advanced imaging study should be prescribed.  This very counter-intuitive finding is captured in the title of a 2002 paper in Radiology from noted radiologist Dr. Thorn Griscom: A Suggestion: Look at the Images First, Before you Read the History.”

Whenever possible, the preferred method involves doing two reads—first, without looking at the projection radiograph, doing a clinical exam or talking to the patient first about their symptoms or getting the history. My goal is to not have any preconceived notions about what the findings may be, let alone the diagnosis. Of course, with CBCT—especially with the focused field—if it’s an upper left side, I have a pretty good idea of where the problem is. But that’s all I really want to know.

I evaluate the study through that lens. I then get the history, look at the projection radiograph, review all the clinical information and perform the clinical exam. After that, I go back and look at the CBCT study again. This approach is very counterintuitive and not widely appreciated.  Current recommendations for approaching are as follows: conduct a thorough clinical exam and radiographic exam before prescribing imaging. In my opinion, that’s backwards, and not based on what has been learned about the interpretive process through careful research in medical radiology. Continue reading

The Possibilities are Limitless

Technology, trends and techniques are constantly changing. With that in mind, Carestream Dental asked a number of experts about their opinions on what oral health care professionals should be on the lookout for in 2017. Here’s what Lisa Moler, publisher of MedMark, had to say:

By Lisa Moler, Publisher, MedMark, LLC

Staying current on dental trends is both exhilarating and challenging for MedMark’s dental journals, Implant Practice US, Orthodontic Practice US, Endodontic Practice US and Dental Sleep Practice. Latest and greatest technologies keep evolving at mind-blowing rates, allowing diagnostic and treatment options to become safer and more efficient—while staying within a reasonable budget.

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The New Endodontics

Classically, the “endodontic triad” for successful treatment outcomes has represented the cornerstone of masterful endodontics. Nothing’s changed; only the methods.

Specifically the triad refers to 1) cleaning (or debridement); shaping (which facilitates cleaning and creates a receptacle for predictable three-dimensional root canal system obturation); and 3) oburation.

The endodontic practitioner of the future is a clinician, scholar, manager, communicator, collaborator and advocate. But the overwhelming goal is to begin to take advantage of the latest technologies and timeless endodontic biologic principles. Continue reading

The Use of CBCT in Identifying Endodontic Lesions

Editor’s note – We recently had the opportunity to speak with Dr. Jeffery B. Price, Clinical Associate Professor and Director of Oral & Maxillofacial Radiology at the University of Maryland School of Dentistry, regarding his work in co-authoring the first chapter of Clinical Applications of Digital Dental Technology. Featuring CBCT scans captured by the CS 9300 system, we asked Dr. Price to explain a little more about the clinical case behind the images.

CBCT image of the posterior left mandible scanned on a CS 9300 unit

CBCT image of the posterior left mandible scanned on a CS 9300 unit.
Images courtesy of Dr. Price from Clinical Applications of Digital Dental Technology

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Why Endodontists Should Add 3D Imaging to Their Practice

By Dr. Nestor Cohenca

I have been using cone beam computed tomography (CBCT) since 2003; in fact, I believe I am one of the first endodontists to incorporate this technology into my practice. In the time since, the evolution of CBCT systems has been impressive.

At its core, I find the following benefits to be instrumental when it comes to utilizing 3D imaging in my endodontic and traumatology cases: Continue reading