Dentistry Uncensored with Howard Farran

How to perform dentistry faster, easier, higher in quality and lower in cost. Subscribe to the podcast: https://podcasts.apple.com/us/podcast/dentistry-uncensored-with-howard-farran/id916907356

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Howard Farran:

It is just a huge honor for me today to be podcast interviewing Dr. Taraneh Maghsoodi-Zahedi. She received her bachelors of art degree from Azad University in Iran in 1992, then she moved to the United States in '95. She received her Bachelor's of Science Degree from UTSA, University of Texas San Antonio, in 2000. She received her DDS in 2006 from the University of Texas Health Science Center, San Antonio, which is the long school name. They need to get an editor. The initials of that are UTHSCSA.

Taraneh:

Well, now it's UT Dentistry.

Howard Farran:

Okay. So they shortened it. All right.

Taraneh:

That's right.

Howard Farran:

So following graduation, she continued her education in maxillofacial radiology program where she received her certificate on December 2009 and master's of science degree. She has been engaged in patient care as the chief maxillofacial radiologist at a nationally recognized imaging center, 360 Imaging, since then.

In 2010, she has joined the University of Texas's Health Science Center in San Antonio as an assistant professor in the periodontics department. She received her board certification for the American Academy of Maxillofacial Radiology in 2010. She has maintained a private practice in academics since 2009. She has published articles in different areas of radiology. She has delivered presentations nationally on 3D imaging, radiographic interpretation and technical skills.

She has been engaged in multiple areas of patient care, such as the evaluation of pathology, trauma, TMJ, implant surgery, maxillofacial reconstruction, cranial facial syndromes, and on and on. She is just passionate about pathology. My first question is, "How does a beautiful woman like you become passionate about pathology? Was this just morbid curiosity?"

Taraneh:

Yes. I think. I'm a problem solver. All my life I've been like that and I did dentistry. When I first started dentist school, I wanted to be a pediatric dentist. After a couple of year, I didn't even know radiology existed. After a couple years, I went to, believe it or not, a Halloween party and I met a lady there. She said, "I'm a radiologist and a dentist. I'm like, "How that could happen?" You know? Then she introduced maxillofacial radiology to me.

We were talking and, you know, she said, "If you want to come down ..." she was still a resident. Dr Mardini. I went there and I look around. At that time, combined CT was not a big deal. They were working on tomography and things like that and I saw so many amazing cases that she was working on. I just got kind of interested. I wasn't thinking, "I'm going to the residency," but, you know, because I was older when I graduated from dental school, I thought about, you know, going into maybe pediatric.

By the time I thought about it, you know, maybe I can do a little bit of a radiology because it's more flexible. What if something happens, you know. We don't really know what happens with them just you'd have an accident, and you can not work anymore, so I said, "You know, maybe because I'm older, I can go to do a specialty that I can practice a little bit longer."

So I just chatted with her for a while, and I just fell in love, and I saw, you know, pathology. The things that we can find, you know, sometimes incidental findings that could save lives and that's when everything got started there. I was thinking about just doing residency and doing general dentistry for a while, and then when I couldn't work anymore I could go to radiology, but I fell in love with it so much. Right after graduation I said I'm going to stay and do this. Then, you know, the combined CT there came along and changed everything.

Howard Farran:

I'm so old. I'm 54. You know, I can still remember the coolest thing that happened in panos is when some genius figured out how to put an r on one side and an l on the other. We all thought that was the greatest update. We thought that was the greatest invention in all of oral radiology. When did 3D cone beam really come about and take place and hit dentistry?

Taraneh:

Well, it started in Iran around 1987. It wasn't that popular and they started working on it. You know, that's the time that it started. '87. 1987. It was only for like implant and because of the, you know, tomography was big for implant. Tomography was a big big deal, but the amount of radiation and, you know, the expenses that was involved made people, you know, kind of gear towards combined CT more.

Then with the new technology, every year they have a new machine that does the better thing. You know, less radiation and that helped dentistry a lot. I think that the first machine that was made was in 1987, but it was transferred from medical CT to combined CT. The amount of the radiation that you get exposed to with combined CT is a lot less. Unfortunately then we see, you know, the amount of radiation is not that much.

People think that they can irradiate any patient that walks in. That is sometimes, you know, when you have children, you don't want, you know, the children get exposed to too much radiation. In the American Academy of Maxillofacial Radiology, we were concerned about, you know, imaging gently. I had a orthodontist calling me and saying, you know, "I want to take a scan on every child that gets into my office, because it's easier. You can move the teeth digitally. You can virtually do your treatment and show it to the parents and the child. This is what I want to do," and I'm like, "No, you can't do that. You have to establish a standard of care and not expose every patient that walks in."

We have to be careful. I know it makes our job so much easier, you know, for implant surgeries, for evaluation of, you know, ortho, perio. It's easier when you use combined CT data, but we have to think about our patients too. Unfortunately, sometimes you know the laziness gets into a practice and we forget that our goal is to take care of a patient. If we can take care of our patients with less radiation, it's going to be more helpful, and it's better for everybody.

Howard Farran:

I love that. Image gently. I wish you'd write an article on that in Dental Town. I really wish that Dental Town magazine, you'd write an article with us. So I'm going to throw the same question at you. What would you say if an endodontist asked you right now commuting to work, "Do you think I should buy a CBCT and image every molar before I do it since the number one cause of a failed root canal is missing a canal? Do you think I should take a 3D image of every molar so I know all the canals before I start?"

Taraneh:

Honestly, no. I don't recommend that because there are a lot of molars that you can do, especially an endodontist. I mean, as a general dentist, I tried that many times and when I am successfully doing that, I'm sure that an endodontist would be successful. It's where the clinical judgment comes into place in my opinion. You know, you can do ... Yes, it is easier to do that and know that I can have a video. I can find it if I could.

That you can virtually go through the canals and look at the pulp and every accessory canal is visible when you have the digital data. You can reconstruct everything. You can take away all the hard tissue and just look at the pulp. That's amazing, but do we want that for our patients? We are not treating just the tooth. We are treating a patient, so we have to consider that.

No. I don't think every tooth needs a CT scan, but I believe that many do. So if you want to buy it and have it in your office and, you know, you can probably have maybe one or two cases that walk into your office that probably need this scan, but not for every patient. No. I don't recommend that.

Howard Farran:

Yeah, but I mean, you're like the only one I hear saying this. I mean, we need to give you a bigger platform and a bigger microphone because you know when you go to a dental convention, that's not what the CBCT guy is saying.

Taraneh:

Because they're selling the machines, right?

Howard Farran:

I know. Money's the answer. What's the question? I wish you'd write an article now because I'll tell you what. I had a personal experience. I got four boys, which means no matter what I do on Earth, I'll get into Heaven just from all that trauma, and pain, and suffering. One of my boys had a bump and we didn't know what it was, so we went down and it was causing pain, so we went down to the emergency room and the lady him back and instantly took a CAT scan.

Then when the doctor got there, he said, "Well, why the hell did you take a CAT scan?" She goes, "Well, because there's a bump." "You don't take a CAT scan for a bump. It's just a little fatty deal. It's nothing." I just thought to myself, "He's a boy. So he had all of his testicles, everything, completely irradiated and she didn't even have a doctor's order to do it."

Taraneh:

Oh my goodness.

Howard Farran:

If the doctor would have came in first ... I mean, the doctor should have written the prescription to go take the CBCT and here at the big hospital in my neighborhood, you know, whoever it was. The LPN, nurse, whatever just went back there and totally irradiated him. So do we have any data at all? Anything we can hang our hat on that says that dental x-rays have an increase of some type of cancer?

Taraneh:

Well, there was an article written a few years ago. A couple of years ago. It was a very controversial article. I can tell you right now, it was a wrong article. They were correlating melanoma with dental x-rays. The funny thing was the bitewings had more effect on the production of melanoma than the entire FMX, which doesn't make sense. It was approved by some organizations. Then they put it in the newspaper.

They say there is a correlation, but it's not proven yet, the thing is radiation is powerful. No matter what. That we know. So why we expose the patients in something that it's going to be hard for them eventually. It is radiation. Then you go into this one. One time I told my patient that, you know, she came in for ... she had a big abcess. This is when I was doing my rotation as a dental student.

She came in and she said, you know, "I have this," and we took an x-ray. We wanted to take an x-ray and she said, "No. I don't want x-ray because it has radiation." She had a radiation phobia. I told her, "You know, walking to your car in San Antonio, Texas, you're going to get more radiation than, you know, just one PA that I want to take to evaluate the apex of the two."

She says, "Nope. I don't want to agree on that. I'm going to leave." So she was leaving and she came back and said, "Can I get you a lead apron to go to my car?" I created a monster now. So, you know, you get radiation. Radiation is harmful, but the amount of radiation that we give our patients for a diagnosis it's more if we decide that it is worth it.

Not every patient needs that amount of radiation. Dental x-rays such as panoramic, and FMX, and wide range, they don't have that much, you know, like at the bottom of the curve if you look at it, they have the least amount of radiation. It's negligible.

Howard Farran:

Do you have a chart comparing brand name, FMX, CBCT that you could email me?

Taraneh:

I do. I do.

Howard Farran:

I wish you would post that on Dental Town. So we have 50 categories and one of the categories. Hang on, let me go to categories. They're in alphabetic order. Anesthesia, assistance, CAD cam. One of them is oral and maxillofacial radiology, imaging, and photography. It would add so much credibility to our site.

So the subcategories are cone beam CT imaging, digital radiography, film radiology, intro of cameras, photography, radiographic diagnosis, and transmitting digital images to payers and providers. I wish you would do that.

I'm going to ask you another question. You said that patient, you created a monster. She wanted to borrow your lead apron. Don't you think there's been a decrease in the use of thyroid collars lately?

Taraneh:

Yes, but the new recommendation is you have to have them. The problem is, because of the amount of radiation, we know it's negligible. That's why people just neglect to do that, but it is recommended, so we have to use it. I don't know how it's in Arizona, but in Texas, ti is recommended. We have to use it.

Howard Farran:

Well, in Texas they just got rid of your specialty. You became a specialist and the Texas courts on that implantology case, so Taraneh, you're not even a specialist anymore. What do you think about that in Texas?

Taraneh:

Well, I'm a specialist in maxillofacial radiology.

Howard Farran:

You know the lawsuit I'm talking to, right?

Taraneh:

No. No. I haven't heard that one. No. I'm sorry.

Howard Farran:

There was in Texas ...

Taraneh:

I have to look into that.

Howard Farran:

The Texas State Dental Association, the tripartite system of The American Dental Association, told a general dentist who was advertising that he was a specialist in implantology to quit saying that because it was not a specialty. So it went to court and the court ruled that The American Dental Association is just a membership organization and they have no jurisdiction and this man in fact only did implants and it was not false and meaningless advertising and said the specialty only applies to your membership organization. It doesn't apply to the consumer market. So actually you are a specialist in oral maxillofacial surgery. You can say that, but if someone else ... Anyways, it's a crazy deal.

Taraneh:

Yeah. I hear in Texas we are very conservative.

Howard Farran:

You're very what?

Taraneh:

We are very conservative about things.

Howard Farran:

Texas is probably one of the most anti-government states out there. I mean, they still refer to them The Lone Star State. I have dentist friends who think Texas should secede from the union and I'm not making this up.

Taraneh:

I'm moving to California then.

Howard Farran:

It might be part of the formula of America's success is that all the people are so cynical about government to begin with.

Taraneh:

Mm-hmm (affirmative). Well, in the Middle East it's even worse.

Howard Farran:

Yeah. So, I'm going to ask you, what percent of the 150,000 general dentists and 30,000 specialists in the United States do you think appropriately use the thyroid collar?

Taraneh:

I would say probably 35%. Don't quote me anywhere because it's not based on any research.

Howard Farran:

What percent do you think take too many x-rays?

Taraneh:

Probably 75.

Howard Farran:

Exactly. To most people who are listening to this as they're commuting to work, is there any simple way to explain the difference in the amount of radiation between a PA, bitewings, and FMX, a pano, and a CBCT? Is there any way for you to orally expand that?

Taraneh:

So if we give a scale of, for example, a bitewing. If the bitewing is about 20, then the FMX is I would say 50 a scale. Then the combined CT's probably a 250. Then a medical CT is 2,500. You know, depending on the machine that you're going to use for a combined CT depending on, you know, the field of view, it's going to be a different amount of radiation. You know, it's all on the discretion of the doctor.

For example, I got an orthodontist calling me the other night and there was a two impacted canines. One I had maybe one third of the canine number 11, but she send it for evaluation update of the impacted canine they got number 6. She put it in a small volume and now she has to send the patient again to the same imaging center to get from the other side.

So for example, if you want to do ortho and you think that there is, you know, two impacted teeth. Maybe I don't know what happened in the mandible. This in the maxilla, so it's better to take a large volume and give the patient a little bit more radiation rather than taking the patient four times. It's four times the radiation. So I think we should, instead of just saying, "You know, okay. Go take an FMX, or take a PA, or whatever," we should kind of direct our assistants to gear the information to encourage them to or order them to take in an evaluation that it's beneficial for the patient.

In this case, I told her, "Why didn't you have the larger volume rather than ...?" You know, she wanted to protect the patient and I understand that, but thinking beforehand, you have to have your treatment plan before sending the patient to the scanning center. This is my point. So you cannot just have everybody and say, "Okay. Take a volume of the entire head, or you know, a small volume. Okay. I have to deal with number 11 now, so go take another scan."

So it's better to do the treatment planning before sending the patient for x-ray imaging. You know, I work in a dental office for a little while and every patient who walked in before even the doctor would have seen the patient, they would have taken, depending on how much the insurance is paying, they had the PAs done. They had the FMX done or panoramic done.

I think the doctor should see the patient, and see what the needs are, look at the chart and see that the patient had an FMX done two years ago and there was nothing wrong with the patient, so why do we have to do it again? Even if the insurance is paying, I know they have a lot of loans to pay. They want to buy that extra book or whatever, but I think we are here to take care of our patients.

This is our main job. To take care of a patient and, you know, you have to realize that this is our job. Not to just, you know, have the x-ray taken. Like your son, you know? He went in. Probably your insurance was good and they said, "Okay. Let's take a scan on this kid," and why?

Let the doctor come here and let him decide what he wants to do and then we go from that's why we are there. Otherwise, you know, they probably could have a machine do that, you know? "Broken bone? Okay. This is what their prescription is." That's why the doctors are in the office. To see the patients.

Howard Farran:

What percent of doctors do you think see the new patient and then order their x-rays versus they walk in there, see them, the dental assistant takes all the x-rays, and then the doctor comes in?

Taraneh:

Maybe 10%.

Howard Farran:

I know, and it's not even legal. You see all these practice management people who are not doctors. They didn't go to dental school. They don't have any initials behind their name. They write these articles in journals and say things like, "Well, how many opportunities do we have to say, "Who's due for their FMX?" Then they check off, "Oh, here's three of our nine patients. They are do for an FMX. Let's get that FMX, because that'll be an extra $100 or whatever."

It's like, "Well, by God, shouldn't the state [inaudible 00:22:05] determine whether you need an FMX?" I mean, what's funny is you look at the six-month recall, but all my dentist friends that I know, I mean, every dentist I know doesn't get their teeth cleaned every six months. They get them cleaned every 9 months, 10 months, 12 months, and they'll get x-rays every maybe one tooth or bitewings every four or five years. Then their own office, everybody marched in just gets an FMX if the insurance pays every three, they do it every three. It's not right.

Taraneh:

Sometimes we forget why we are where we are. That's the problem. That is why I'm in a admission committee at The University of Texas for dental students because we want people who come here to have a passion about taking care of the patients. It's funny that ... Sorry.

Howard Farran:

No, that's me calling you. That was me.

Taraneh:

Yeah. You know, sometimes they even have the mirrors to tell me. You know, I'm interviewing them and they say, "Oh, I wanted to be a doctor, but you know, you can get paid better when you're a dentist." I'm like, "Okay. You are not going to have ..." If it's just for the money that you can make ... I mean, the money is good. You never see like a dentist begging in the street. I mean, if you want to make money, I think you should go to real estate. This is what my recommendation is. Not a doctor. You want to take care of patients.

Howard Farran:

You can marry more money in a minute than you can earn in a lifetime.

Taraneh:

That's true.

Howard Farran:

I say if you were to be a millionaire, just find that 80 year-old lady who's worth $10 million.

Taraneh:

That's right.

Howard Farran:

Her husband died 20 years ago. Just find that lady. So we both agree that x-rays are taken 90% of the time in a doctor's diagnose. We both agree that if you say that every new patient gets an FMX, or you say every new orthodontic star gets a CBCT, and that every molar endo at an endodontist gets a CBCT, that's just not right.

Taraneh:

Yeah, it's not right. You have to have a [crosstalk 00:24:21].

Howard Farran:

You need to write that article because the noise of the industry is everybody selling a CBCT, you know, they go to these magazines. They say, you know, not my magazine. They go to some magazine. They say, "You print this article and we'll buy a full-page ad next to it."

They buy these big booths at the conventions. They've got all these sales people and so you're saying with worst message because there's no money involved. In fact, if I listen to you, I make less money. Who the hell's going to promote that? I'll promote the shit out it on Dental Town. Write an article. I like that. I had never heard of that before. Image gently.

Taraneh:

Yes.

Howard Farran:

The other thing I got to ... I know my dentist. I do. I mean, I know them so well that a lot of them are just technology ... They just love technology. Whether it's their iPhone, their iPad, they just love it all. So the CBCT is like kind of buying a Ferrari, a boat, and a girlfriend all wrapped up into one. They love that thing and now 3D imagine is getting connected to 3D printing, right?

Taraneh:

Yes. Yes.

Howard Farran:

Talk about that. How's that coming along? Tell us about all that.

Taraneh:

Well, the case that I have, it's showing that too. So you can buy a machine and just do everything. You can even fabricate your own surgical guide using this. You know, it's a trend and if you have the extra money ...

Howard Farran:

It's a fad.

Taraneh:

Yes.

Howard Farran:

Go to University of Texas. Got to all those ... Find any oral surgeon or periodontist that's placed 5,000 implants or more they've never used a surgical guide. It's because they're surgeons. It's because when they lay the tissue back and they see a second bicuspid and a second molar, they're pretty damn sure the implant goes in between it from [inaudible 00:26:14] distal and they're going to split the [inaudible 00:26:16] in half. I don't know anybody who's placed 5,000 implants in their life who would even recommend a surgical guide, but I know it's a huge fad in dentistry.

Taraneh:

It is and the thing is, sometimes I am a maxillofacial radiologist and I see a lot of cases that confident people ... You know, sometimes we get overconfident and then you come up with a lot of disastrous cases that we see. I can tell you once a week I have a case that that happened, you know?

Howard Farran:

With a surgical guide?

Taraneh:

Without the surgical guides. They're so confident.

Howard Farran:

Oh, you mean they're so confident without a surgical guide.

Taraneh:

Yes and then they mess it up.

Howard Farran:

So you're saying from what you see once a week that you recommend a surgical guide?

Taraneh:

I do. I do. Honestly.

Howard Farran:

Interesting.

Taraneh:

Yes.

Howard Farran:

Because I'm 54. Every one of my friends that's 60 to 75 that's placed 5 to 10,000 goes, "Yeah, yeah. Why don't you get a surgical guide and put training wheels on your bicycle? Grow up. Learn how to be a surgeon. Take the training wheels off. Go do it."

Taraneh:

This is the same approach as the combined CT. Not every case that comes into your office needs a surgical guide, but there are cases that really do.

Howard Farran:

Okay. Well, what about replacing a ... When you look at the 32 teeth from the hundreds of millions of claims by the insurance shows there's only four spikes, and it's the six-year molars. That's the tooth with the most root canals. The most extracted. Most bridged. So you go, you know, along one, two, three, four, five. Boom. Then it's seven, eight, nine, ten, eleven. Then when you get to 14, boom. So for just missing a first molar, which is the most common tooth to be replaces with an implant, a bridge, a root canal. Would you recommend a surgical guide for that?

Taraneh:

Probably not for just a single implant, but I wouldn't mind taking a scan to see if there is maybe a undercut. If you touch it and you don't feel the bone all the way, probably you need the combined CT and probably for one single implant no. Even with that sometimes you have, you know, a very thin buckle plate that you want to avoid perforating. So in that case, like for anterior teeth. For eight to nine, I definitely recommend it because half a millimeter could save a tooth.

Howard Farran:

Well, number one, let's be clear. Eight and nine, you refer that case to whoever you hate the most. Find the periodontist ... Especially, now if it was a 70 year-old man with a liver spot, you can do eight or nine, but if it's a woman under age 100, you're married to that case until it looks pretty.

Taraneh:

That's right.

Howard Farran:

A lot of times those cases don't turn out pretty. I just don't think you make any money replacing incisors with implants on women. I mean, you don't.

Taraneh:

Yeah. You're right.

Howard Farran:

Like me, I'm 54. I'm fat. I'm bald. I don't show any of my teeth. I look like I'm talking without my upper denture in. You know, all that tooth has to do is work, but if it was in a woman, she'd stretch her lip back over her head and if she could see anything wrong with it, she's going to be right back at your front desk. So number one, you got to pick profitable cases and incisors on women are not profitable cases. You know, then if you've got some periodontist or oral surgeon that you hate, send them there or a [inaudible 00:30:07].

Taraneh:

That's good. For those I definitely recommend surgical guides. I have a case I want to show you. Let me see if I can show this. This is an exciting ...

Howard Farran:

You told me you had 100 cases to show me.

Taraneh:

I do, but this one I opened it here just for you. It's particular for you. All right. Okay. This is a case that I wanted to share with you. We had a 65 year-old male with a lot of problems. Dental problems. Attrition, several restorations, several missing. This is a pre-op digital impression. Then we made a model, a digital model where we actually made a model from the digital scan. Then all we did was establish like that. Then you can put markers on the model.

Since you need a certain amount of space to put your implant and restoration, you can mark the model. Then you can make it a digital model with alignment markers and this is from the model. Then you establish the OBD. So this is the mark that you put and you have to have reduction of bone on this. For this cases, you definitely need surgical guides. So you'll mark that, and then mount it, and then you reduce the amount of bone on the model and then take another ... You digitize that.

This is after the bone reduction. Then you set the teeth, the mandibular teeth, which is opposing to the natural patient's teeth, you get a bite registration and you index the cross-mounted incisal edge and position the maxillary wax up as well. We're going to go this way. All right. You can take a scan of the entire wax up from the mandible and the maxilla. Then this is the actual patient's scan and this is the bone that is reduced, and this is the digitize bone reduction with the wax up.

So you have all of these information and you can superimpose them with this markers at the beginning. Then we can print a model and mount it into the existing opposing teeth and get the bite registration with where the bite is that we had initially. Then you can remove the tooth-mounting jig and this is the amount of bone that can be reduced. This is how you can look at the articulation with the maxillary teeth. Then you choose your correct analog and position it into the slot that you want.

Then put your [inaudible 00:33:09] in there and this is how they orient when you look at it on the side [inaudible 00:33:18] view. Then you protect the screws and the abutment before processing. This is the actual dentures. Then you have the bite registration between the maxillary natural dentition and the mandibular dentures. You fill the [inaudible 00:33:40] area with the PVC. So this is how it's going to look.

The mandibular teeth with the bite registration and the maxillary natural teeth. Then you prepare the denture for surgical conversion. So you're making your drill holes on the dentures and get it ready and create a bone to denture transfer jig by putting like a heavy-body PVC between the denture and the reduced bone. This is how we can put the temporary abutment and adjust the denture for access.

So this is all done before you start the surgery, so everything is ready. This saves a lot of time for patients and for the doctor. This covers the bone and the implants are coming out of it. This is what it's ready for shipment. You have the upper denture. You have the lower denture with the bite registration and we can make your ... Okay. This is how the 360 Imaging has its own software for implantile treatment planning.

This is the actual implant and this is the amount of bone that they have to reduce in order to establish enough space for restoration. You can change the angulation of the implant and then this is how it's going to look when it's finished. This is superimposition on all of those components that I showed you a few slides ago. Like here. This is a superimposition of all of those data.

These are where the implants are going to go and these are the fixation screws. This is the actually patient's bone with the reduction and everything. This is an axial view of the patient when it's done. So you'll have the bone and you'll have the denture. This is where the four implants are going to go and these are the fixation pins to hold all of these together.

This is when the surgery is done and everything is perfect. This is all done virtually, so do your surgery even before putting the patient in the chair. This is a case that we did with Doctor Cohen. He's a periodontist and he sent a patient for the scan and everything.

Howard Farran:

What was his first name?

Taraneh:

William. William Cohen.

Howard Farran:

In Seattle? No, that's Michael Cohen.

Taraneh:

No. He's from Saint Louis. He's from Saint Louis I think. So these are the steps that we go or the surgeon goes through. This is the extracted teeth. The flap is made and this is the [inaudible 00:37:10] reduction of a guide and a vertical mount guide. This one when the vertical mount guide is removed and then the bone is reduced. Then you can put the surgical guide on the top and then start doing it.

I want to show you step by step. This is after extraction. The flap is made. This is the bone reduction guide. You put that on the patient and then screw it or make it stable. This is the vertical mount so we know how much of the bone reduction is going to be done. Bone reduction guard with vertical mount. This is the screw that's with the connection pin that put everything together and keeps everything stable during the surgery.

This is the reduced bone. So at this point, the bone reduction guide is in place and it's stable. Then we take away the vertical mount guide. This is the surgical guide that we put in for surgery. All right. Sometimes you have to do a lot of reduction. Then the height of bone in the anterior and posterior aspect of the mandible or maxilla there's going to be a lot of difference. So we don't want extra tissue. What we do is we reduce this area a little bit too.

The surgeon does. Not us. The surgeon. So there is not much of that extra tissue hanging in there. This is the articulation piece and this is the analog model with articulation. This shows the anatomy of the patient as they show up in the oral surgery suite. This is a collaboration between Doctor William Cohen and Barry Goldberg. Doctor Goldberg was the surgeon on this case.

Look at this patient's smile. He is smiling. He's a happy guy, but you know, the smile is a little bit reserved. This is a closeup of it. So this after extraction and a flap. The bone reduction guide and the vertical mount guide in place in here and the screw is putting it together. They articulate together. The vertical bone guide is removed and you have the reduction guide in place. So we reduce this amount of bone like that and then the surgical guide is in place now with the screws. All fixed.

So nothing changes. You go in and put in your denture [inaudible 00:40:15]. We put the temporary denture that is going to articulate using the bite registration with the opposing teeth. Now we're going to work on the maxilla. We put the bone reduction guide in the maxilla. Now we don't need the vertical mount guide and this upper implants. We do the bone reduction, place the surgical guide in there, put the four implants in the maxilla, and these are the implants.

I don't know if you can see it here. These are the implants. On this slide it's not that visible that much, but then, you switch it. The lower, the maxillary dentures and this is the temporary. So the patient leaves the office just like that and this surgery doesn't take more than an hour and a half. This is how the patient looks like now. I know we don't have that much time, but I want to show you something.

Howard Farran:

What do you mean we don't have that much time? It's Friday.

Taraneh:

I know.

Howard Farran:

It's 2 pm on a Friday. Then we have Memorial Day weekend. I would listen to you for 40 days and 40 nights. By the way, if you're listening to this on iTunes, this is one of those cases you're going to want to watch on Dental Town, YouTube, or Facebook because these are amazing cases. By the way, man, I wish you would start posting cases like this on Dental Town. Taraneh, these are amazing.

Taraneh:

Yes. I agree with you.

Howard Farran:

Show me all the case you want to show me.

Taraneh:

Okay. All right. I have another case. This is what really made me love pathology. Not because, you know, I like people to get sick, but my daughter was 15 when I saw this case and it really touched me. This is a case of a 15 year-old female. Let me go from the top and I'll show you what's happening here. This is a 15 year-old female and my daughter was at the same age.

This is an orthodontist who finished the ortho treatment and on the panoramic image that he took after finishing the treatment, he noticed something on the right side of the patient maxillary. The right side. He wasn't sure, so he took a scan and sent it to me. When I saw this case, I was really really ... I couldn't sleep that night. Honestly. Somebody told me "When I saw this case I went to bed and I slept like a baby, that means I woke up every two hours. I cried." So that's exactly what happened.

I was really touched by this case. As you can see here, there is a large soft tissue mass on the right maxilla. Let me just draw a panoramic image because we all love to look at the panoramic. You see there is a large [inaudible 00:43:35] right here. This is a panoramic reconstruction for the combined CT and there is a severe root absorption in the area of three, four, five. When you look through the slices, there is an interruption of the floor of the ...

Let me make this bigger. Floor of the nasal cavity. Floor of the right maxillary sinus. Severe root absorption. This only happens in, you know, know severe root absorption with no movement of the cheek. I mean, I was devastated, you know? This kid at this age it's a probably malignant tumor. I send it to the doctor and I send a report. I said, "This is a malignancy. We have to do advanced imaging later, but for now, let's do a biopsy in that area to see what's going on," and we do it right away. We need it to be an emergency.

The poor orthodontist sent me a prior, you know, the x-ray prior to the treatment and you could hardly see it at the beginning of the treatment, so it was just a small little radiolucency that it was not even very obvious in the panel. So when I looked at the ... You know, the patient had several panoramic, it had gotten bigger and bigger. Then I realized this patient had ortho. So there was braces. So because of the presences of braces, this could not move.

The biopsy result came back as a circular giant-cell granuloma. If you look into any type of literature review or any book for circular giant-cell granuloma, first of all, it's multilocular This one is a large mass without the locularation. It passes the midline. This one stops right at the midline. The more aggressive types, they have root absorption, but not this extensive and they hardly have a lot of bone absorption as you can see here.

So Doctor Langley was my mentor and taught me radiology. He always said "Pathology never reads books." So I think that was one of the ... I'm glad this patient does not have a malignant tumor, but you know, she basically lost one fourth of her mouth. It's fortunate that it's not malignant, so she doesn't have to go through radiation and chemotherapy, but you know, it looked really scary and I couldn't sleep at night because, you know, my daughter was the same age. I mean, even if it wasn't enough of a similarity that I could feel this feeling that I always feel when the patients have things like that. It's just heartbreaking.

You know, I don't want to scare people, but if you see even the smallest thing, especially in ortho, you know, you have to pay attention. If you see it's getting more, maybe we should have ... This is when we need combined CT and this is ... I stand by it. I can go to any court and say, "You know, we need these combined CT," but everybody walks in does not need a [inaudible 00:47:26] CT in my opinion. So yeah, this was an interesting case that doesn't match any textbook description of this region. Well, did I scare you too much?

Howard Farran:

No. I'm loving it. I'm loving it.

Taraneh:

All right. So yeah, this is a case that kind of bugged me for a while, but after I found out that the patient did not have cancer, but it has the appearance, you know, the behavior of this pathology it looks really malignant, but thank God it was not malignant. You know, we have to consider the presences of the braces because the teeth could not go anywhere so they start absorbing.

If braces were not there, it would have probably a lot of displacement. That's why, you know, we say the pathology doesn't read books. So this is a very interesting case and always dear to my heart. The patient did okay. They did plan on putting implants later on, but for now she's wearing dentures. Do you have any questions?

Howard Farran:

Well, I did have questions on ... Well, first of all, you are also the oral and maxillofacial radiologists for 360 Imaging out of Georgia.

Taraneh:

Yes.

Howard Farran:

Explain what that company is, and what they do, and what you do for them.

Taraneh:

I am their maxillofacial radiologist. I'm on a board. I work five days with 360 Imaging. What I do is I look at mostly all of the scans. We have trained treatment planners. Some of them are dentists and what they do is any case that comes in, they look at it. If they see something that's out of ordinary, they call me and send me the scans. I get all of the scans, so they tell me, "Okay. Look at this and see what you think."

If there is anything going on, I just let them know and I add a radiology report. I do between 15 to 20 cases a day for them. For the people that they request radiology report. Any other cases that we see anything out of the ordinary, we let the doctor know that we see a pathology and that happens several times. I've been working with 360 Imaging for the last, oh, it's more than nine years. Almost 10 years now.

We had several cases that the patient was sent. Like I have another case I can show you really quick. Yeah, this one. This one was a case that it was just an implant case. I look at it and I saw some ... Hold on. Let me ... Just a second. So I look at everything. What 360 imaging does, we have imaging centers that we can take scans on the patient. From that time on until the implant is placed into the patient's mouth, we have services. Surgical guides, 3D printing. We do all of that services in Atlanta, Georgia.

So the timing is awesome. You know, people used to send their scans to Belgium to, you know, make surgical guides. This is happening, I mean, if it's a rush case, we can do it in 48 hours. So it's faster. I'm available all the time. I have people from California calling me. I have people from Europe calling me. You know, if there is some emergency, you know at 6 o'clock California time or you know, the doctor is doing a extraction and a root tip is in the sinus. Descended and I look at it.

I work from home most of the time. I go to school two half days. I'm a part-timer at the University of Texas. If there's an emergency, I'm always available, so we give that service. That happened a few times. We can make anything. You can treatment plan it and then after treatment plan, we call the doctor and go over the treatment planning and the doctor decides if he wants to go with the treatment plan that we've proposed or he wants to have it, you know, a little bit of change here and there. Maybe do that and then we do fabricated our own surgical guides.

Howard Farran:

On your website it's 360 Imaging.com. I love you have two testimonials. One of them is from Doctor Robert Bruce MacDonald DDS. This is so funny because I just said this earlier in the podcast. He says, and I quote, "It's funny. My CAD designer and I at 360 Imaging lecture about digital design workflow and guided surgery all the time. The young docs nod. They get it. The older docs shake their heads and say, 'I've been putting them in for years with no stinking guides and I ain't going to start using them now.'"

I think it's almost a generational thing. In the lab side of our business, we try to make miracles out of poorly placed implants every day. We may just have to win this battle through attrition. I truly appreciate all the work you guys do since we have been doing all guided surgery placements that has my life as a dentist and as a lab owner a lot easier. That's pretty amazing.

So you guys are huge in this space. My gosh. You've done 200,000 guided implants and 75,000 dental offices. Holy moly. That's a lot. As a oral/maxillofacial radiologist, and back to the question on guided surgeries, how often are you seeing a mistake. A implant placed. A mistake. A disaster. What are lessons learned that you can transfer to everyone listening to you right now form the oral and maxillo-radiologist point of view on implant placement?

Taraneh:

Well, as I said before, every case is different. Some cases are easy and you can put an implant in, you know, in a space that's available with no problem. We are the doctors or the people who see the patients have to take control of the treatment plan. If there is an area that you are not sure about it, it's better to put the surgical guide and go through all of the steps of prefect treatment planning beforehand. How many times have you done something and you said, "If I do it again, I'll do a better job?"

It's the same thing. You do the exact surgery digitally without harming anybody prior to doing the actual surgery. So I mean, if it was me, I'd rather do it in a shorter amount of time. It's saved me time. Saved me money because if I save time, I don't have to pay my assistant for another extra hour. Then I'm going to, you know, struggle with an implant and put it [inaudible 00:55:03]. Where should I put it? What is the angulation? What outcome is going to come?

When you have a surgical guide, you know this beforehand. You even have the restoration plans beforehand. So everything is done. I'm not saying there is no mistake, but there is a very small chance of a mistake. Honestly every week probably I have one or two cases that are done and now the implants are failing or there is obstinate implants that are out of the avuelar bone. Sometimes even in soft tissue.

You know, the angulation of the avuelar bone sometimes is not enough for an implant and you got with the contour of the teeth that are erupted and then you miss it and you perforate through the lingual or even [inaudible 00:55:56] plates. So in my opinion, I mean, if you can do something better faster, save time for yourself, and money, why not use it, you know? How much is the surgical guide? $250 extra? If it's going to save you a big lawsuit, I think it's a wise thing to do.

You know, since we are looking at every scans, I mean, it's safer to have another set of eyes look at it. Even if, you know, even if it's a simple case, if you're 100% sure that's fine. Go ahead and do it. I've seen a lot of successful implants without the surgical guide, but those are mostly single implants. Even if you have a single implant and you're not sure about it, I would recommend a surgical guide. It's saving time.

Howard Farran:

Which CBCTs do you like the most?

Taraneh:

That's a what do they call it? The 1 million dollar question? Depending on what you're doing. Like, you know, if you want ...

Howard Farran:

If you're an endodontist doing [inaudible 00:57:09].

Taraneh:

I don't want to sound like a salesman or a saleswoman. For endo, you know, [inaudible 00:57:20] has a good machine with a reasonable price. [inaudible 00:57:26] has a good machine. These are the scans that I've seen and when you transfer the data to another, you know, sometimes some scans are really good when you look at it on their own software. Then when you transfer it to another software, they look bad. Then you want to do implant planning on those. That's not going to work. [inaudible 00:57:47] and ...

Howard Farran:

Well, what model number on the [inaudible 00:57:52]?

Taraneh:

Oh, gosh. Now I'm going to really really sound like I'm a saleswoman.

Howard Farran:

No, no, no. You take scans from everyone.

Taraneh:

I don't know the exact name of them. There are several, but [inaudible 00:58:08], I mean, their machines is really good. It's a little bit on the pricey scale, but if you want to do endo, their resolution is awesome and they have their own software that comes with it. Even if you transfer it to another software, it looks good.

Howard Farran:

What about ortho where you need both jaws?

Taraneh:

The ICAT.

Howard Farran:

The ICAT you like the best?

Taraneh:

Yes.

Howard Farran:

Now which one did Invisalign buy? ICAT or I[inaudible 00:58:41]?

Taraneh:

[inaudible 00:58:45] I believe. I'm not sure. I'm not into companies. I try not to endorse any.

Howard Farran:

I know, but they ...

Taraneh:

They're all good.

Howard Farran:

My homies want to know. You're seeing scans from everybody, so what if you were an implantologist? What if you'd placed implants a lot? An oral surgeon, a periodontist who placed a lot of implants. Which system would you like?

Taraneh:

I love ICAT and [inaudible 00:59:09]. I mean, all of them are basically similar, but you know, the ones that I see the most, you know, they're all good, but there are some that they are like as a I said, [inaudible 00:59:25] gives more resolution. For endo that looks really good. There are some features on Kodak that you can get a smaller volume and get the same amount of ...

Howard Farran:

Kodak. You're giving away your age. [inaudible 00:59:39] isn't owned by Kodak.

Taraneh:

Okay. No, no, no. Sorry. I don't want to give my age.

Howard Farran:

Yeah, Kodak sold that [inaudible 00:59:46], right?

Taraneh:

Yes, I know. I [inaudible 00:59:49].

Howard Farran:

Then for you guys driving that can't take notes, I just retweeted @360imaging.com so you can find their website. So you can follow me on Twitter @howardfarran. My last retweet was @360imaging.com. So, I mean, obviously that company's got to be very good if they were able to attract, retain, and keep you onboard for a decade. You must really like 360 Imagining.

Taraneh:

I do. I do. It's like a family to me now after 10 years. Mr. Palmer interviewed me while I was still a resident and we got that connection and, you know, we are just like family. So I'm happy. That's why I'm there. It looks like they're happy.

Howard Farran:

Well, I think the best marketing you could do for them is start posting a bunch of cases on Dental Town.

Taraneh:

All right. We'll do that.

Howard Farran:

See, some people post cases under oral radiology. Some people you might want to create an online [inaudible 01:01:00] course. We did a podcast or you could write a article for Dental Town. I wish you'd do all of the above because one of the problems I see in the field is they'll make a big investment in a CBCT. They spend 100 grand buying it and then they need hours and hours of endless training. I almost think a CBCT and a CAD cam is like buying a grand piano. Just because you buy a grand piano, you're not Beethoven.

Taraneh:

That's right.

Howard Farran:

Once you buy that CBCT, I mean, even years after you've had one and thousands of scans later, you still see stuff on there every day that you have no idea what it is. Same thing with those. You know, so there's a art and a science. Just because you buy a CBCT doesn't mean you're a oral maxillofacial radiologist.

Taraneh:

Yes. I mean, I've heard people say, "You know, I took a course and I can read my scans." I mean, it's good that you can, when you take a course, the idea of taking the course and looking at this is so you can recognize something that's out of the ordinary.

Howard Farran:

You know, another thing I think we could do, you know, we have a continuing education division because we have that yearly town meeting every year in April. In the first 15 years, it was in Vegas and now we're switching the format to Orlando, so we signed up the next two years we'll be in Orlando. The rest of the year, we put on courses. We've put on [inaudible 01:02:31] courses, but putting on a course, reading CBCTs, I don't know how big a class size. How many student you would want.

I don't know your [inaudible 01:02:45] on that, but I know this. We can sell out every single course. I mean, you could do literally one a month. You email me Howard at Dental Town and say, if you want to give courses on reading CBCTs, whether you want them to fly to you, or you want to go on the road, or do it at 360 Imaging in Atlanta, Georgia.

I know this. I know my homies and there's thousands and thousands of dentists who made this huge investment to CBCT and they're on Dental Town crying, "I can't read these damn things. I need more training," because they're also emailing me all the time for what they want Dental Town to do for them, and I get a gazillion requests and they want online courses on how to read these CBCTs.

I know they want in the flesh, hands-on, where they can bring CBCTs, and go over them with you, or show them. If you ever put together a model, you know, is this something you'd only want five students? 10? 20? I doubt you could put 100 in a room doing that, but I don't know. Just thoughts. You know, I'm just thinking out loud with you. I was so honored that I got you on the show. I mean, you've probably read more scans than anybody I know for a decade. You got in on this at the front. I just want to thank you so much for coming on my show.

Taraneh:

You're welcome.

Howard Farran:

If you listen to this on iTunes, go back and follow this on YouTube. Our YouTube channel is youtube.com/dentaltownmagazine or you could see it on my Facebook. What is my Facebook page? Just facebook.com/howardfarran or on Dental Town. I hope you write us some articles. I hope you post cases on the message boards. I hope you post online [inaudible 01:04:29]. We'll do anything you want to do.

Taraneh:

Thank you so much.

Howard Farran:

You're ina sweet spot of the technological revolution.

Taraneh:

Thank you. It was a pleasure doing this. I'm excited and I'll probably do that. I'll take you up on that. I think it's beneficial for everybody. I enjoyed this and I'm going to enjoy doing those. We'll talk about it. That would be great. I appreciate this opportunity.

Howard Farran:

Oh, the pleasure and honor was all mine. The only reason this show is popular is because I'm able to get great guest like you to come on and you just rocked everyone's world. So thanks for coming on the show today.

Taraneh:

You're welcome. Thank you.