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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Dr. Miles is Adjunct Professor of Oral and Maxillofacial Radiology with the University of Texas in San Antonio. He was Chair of the Department of Oral Health Sciences at the University of Kentucky, the graduate program director of Diagnostic Sciences at Indiana University, and has held positions at the University of Connecticut and Dalhousie University, and the Arizona School of Dentistry & Oral Health. He is a diplomate of the American Board of Oral and Maxillofacial Radiology and the American Board of Oral Medicine. Dr. Miles has been selected as one of the “TOP CLINICIANS IN CE” for the past 12 years by Dentistry Today. He has authored over 135 scientific articles, 6 radiology textbooks and the best-selling atlas on cone beam imaging, “Atlas of Cone Beam Imaging for Dental Applications”. He has a website for teaching the dental team about digital imaging at http://learndigital.net/ and cone beam imaging at http://doctorconebeam.com/. Dr. Miles has a full-time practice in oral and maxillofacial radiology in Fountain Hills, AZ. To date he has read over 23,000 cone beam scans.

http://easyriter.com/

https://www.imagegently.org/Roles-What-can-I-do/Parent/Dentist

Howard: It is just a huge honor to bring back my buddy, Dale Miles who lives up the street in Fountain Hills, Arizona. Thank you so much.You were in episode sixteen, so when we started this show, you were like the first person I contacted and you finally signed up on episode sixteen and I wanted to bring you back a thousand shows later because your field changes so rapidly. Let me read your bio. Dr. Dale Miles is adjunct professor of oral and maxillofacial radiology with the University of Texas in San Antonio. He was Chair of the Department of Oral Health Sciences at the University of Kentucky, the Graduate Program Director of Diagnostic Sciences at Indiana University and has held positions at the University of Connecticut and Dalhousie University and the Arizona School of Dentistry and Oral Health. He is a diplomat of the American board of Oral and Maxillofacial Radiology and the American Board of Oral Medicine. Dr. Miles has been selected as one of the top clinicians and CE for the past twelve years by Dentistry Today. He has authored over one hundred and thirty-five scientific articles, six radiology textbooks and the bestselling Atlas on cone beam images, Atlas of cone beam imaging for dental applications. He has a website for teaching the dental team about digital imaging at learndigital.net and cone beam imaging at drconebeam.com. Dr. Miles has a full-time practice in oral and maxillofacial radiology in Fountain Hills, Arizona. To date, he has read over twenty-three thousand cone beam scans and at first today, I thought I was going to be a bad day because I woke up to look out the window. I showed you that picture, it was a scorpion two inches long, but the good news is that you were the next person I saw. So I went from a scorpion to Dale Miles, so Dale, what's really changed since episode sixteen which was, believe it or not, three years ago?

Dale: I can believe it was three years ago. A whole bunch of things have changed in the industry. First of all, as I sort of predicted, most cone beam manufacturers went to a variable size field of view. Early on in the day there used to be small fields of view and large fields of view and not a whole bunch in between. Now, most machine manufacturers actually have devices that can vary the size of the field of view. So they have much more application in the practice with dentistry. Software’s improved. Service, there's some companies that do good service; there’s some companies that like to sell and then don't provide the service afterwards. I'm not going to mention any names.

Howard: Oh, come on, it’s Dentistry Uncensored.

Dale: I know. They censor themselves, actually. The word goes through the industry so.

Howard: Well, it used to be small fields because the endodontist really wanted to find that extra canal in a molar all the way to the large fields where the orthodontist wanted to. So on these variable things when they switched to small field, is it really good enough for an endodontist? 

Dale: Good question. I don't think it ever really was and that's my opinion because the smaller the field of view, what happens is they changed the exposure factors and it introduces noise into the system. So I get small fields of view from endodontists that even though there's some detail that's a little bit better and if there's enough noise that it's a trade-off. So most of the machines now are dental alveolar, so eight by eight or nine by thirteen.

Howard: And what unit is that eight by eight?

Dale: Sorry?

Howard: What unit is that? 

Dale: Oh, that's centimeters.

Howard: Eight by eight centimeters and the other one's nine by?

Dale: Nine by thirteen and again, they vary. If you go to the websites for the different manufacturers, they'll show you all the different sizes that they're capable of doing. And when you asked me about the endodontists, a lot of the endodontists ended up abandoning the small field of view because as you and I know as dentists, we would get a patient or send a patient to an endodontist that needed a root canal in the lower left and one in the upper right. Well, if you have a tiny field of view, you have to take two volumes. So they saw more applicability in having a slightly larger field of view. 

So the popular sizes are probably the eight by eight centimeter and up and the image quality is quite good in all of them. There are a couple manufacturers that still don't have the information and if you're out there listening, one of the things I did early on is I told a company called Planmeca that I did some consulting for, that they needed to add filtration before the detector. In other words, they needed to get out the low end, low energy X-rays that capture soft tissue because the soft tissue would come out in the scan and it was hard to get rid of so their image quality was poor. So I said, you need to put copper filtration on your machine and they did. They retrofitted all the early machines. 

There’s still manufacturers that I think could clean up their images. Valtech being one, maybe even Carestream, I'm trying to think, there's one other that I get in all my clients, oh, the original Sirona’s, they were terrible. The Galileos, the new machines are quite good, but they still get a lot of soft tissue capture and you need to get rid of that in order to have the higher bone detail for the things we do in dentistry. 

Howard: I got a theory about Planmeca. 

Dale: Yeah.

Howard: When you go up to Scandinavia, you visit Planmeca in Helsinki, Finland and 3Shape in Copenhagen, Denmark. It is so far north, in the winter, it's virtually unlivable for like nine months and so the only way to cope is either work twelve hours a day, seven days a week.

Dale: Or invent something.

Howard: Or you drink. 

Dale: Oh, that's true too. 

Howard: And so you go in those companies and their employees, I mean, they're in this lit building with all these people and for ten months, man, nobody works harder. And I had the same theory when I went to Creighton, is that when I got my MBA at ASU, it was great weather, everybody's going to skateboarding and wearing shorts and everybody's partying. But I went to college in Creighton and so many times on a Friday or Saturday, we'd look out the window and it was just like sleet, snow, drizzle. We’re like, “Well, might as well just stay in and study” because you couldn't go outside and I thought to myself at ASU, if I were stay at ASU in undergrad, I probably would've flunked out; there's so many things to do. 

This is Dentistry Uncensored so I want to start with just the controversial, the ugly, the gross. There's a lot of people that think this is a lot more radiation and that these kids, they get a stomach pain and they’re six years old and they take him to the emergency room. They do a CAT scan of their stomach and then they go to the orthodontist for ortho, they're doing a CAT scan of their head and that a lot of kids by twenty-one, they've already had six CAT scans and that this is not good. This is too much radiation. What do you say to all that? 

Dale: Well, it's not just me. It's the entire medical and dental profession; they're basically endorsing a campaign. I'm going to talk a little bit about Image Gently. The dose from cone beam is very low. If I had to give you some numbers, typical machines and it varies because of the size of field of view and the exposure factors and other things in the machine itself anywhere from twelve to fifteen microsieverts to a hundred and you don't have to worry about the units, just listen to the next numbers. 

A medical CT of the head and neck is about two thousand and one hundred microsieverts. So we're way down in the low end.

Howard: You’re fifteen what?

Dale: We’re fifteen to twenty for some machines up to maybe a hundred to a hundred and twenty for others and anything in between depending on all those exposure factors. Now here's the deal, though with medical has gotten, it has improved and there are occasions, childhood tumor, brain tumor, you need CTNMR Information so there's no way around that. But this Image Gently campaign, which is a public campaign has been endorsed, I think I sent you a link to look at, endorsed by the ADA, the ADHA, every dental professional specialty and now the FDI and others. It's really a campaign to reduce CT dose to children. 

However, when dentistry got involved, what they did is they resurrected a number of things that we've been teaching people all these years in schools that they still don't do. So I'm going to do a Karl Rove thing on you here. I know you didn't anticipate this, but I'm going to the whiteboard. 

Howard: Karl Rove?

Dale: You know Karl Rove? Former—anyway, he was—

Howard: Send me Karl Rove. Well, what is he, a former what?

Dale: Oh, you obviously watch liberal TV and you don't watch Fox News. Karl Rove is basically a guy that worked in the Reagan administration who was the architect of the contract with America kind of thing and he always brings these clipboards, these whiteboards because he does, they ask them political questions on who's doing how well in what state. 

Howard: Just want to say imagegently.org and on Twitter they're @ImageGently and I just retweeted. A lot of times you don't follow me on Twitter, you're wondering, “Well, why is Howard tweeting this company or that company or whatever.” “Is that an advertisement?” I've never been paid a penny. I don't sell my retweets. It's just so I know you're driving to work right now and so you can go back when you listen to podcasts and so I just retweeted that. But anyway. 

Dale: Okay. So what I was trying to get at—

Howard: Oh, Karl Rove! Yeah, that guy. 

Dale: Yeah, that guy. You can put his bit—

Howard: Good-looking, bold, handsome man.

Dale: So the two things that I sent you that we're talking points today were the collimation of the dental X-ray beam and the use of cone beam only when necessary. So this is where we are on this particular list, but these are the six things that all the organizations in dentistry have now agreed to and you can pledge to this online. You can go to imagegently.org and pledged to do these things and so my pledge because I don't have a practice anymore, I read cone beam scans, was to actually go ahead and help disseminate this knowledge or this information. 

So I'm going to go through the list really quickly and I know I'm going to hog the speech pattern here for just a sec. 

Howard: No, take all your time buddy. 

Dale: Number one is to select your X-rays. What does that mean? Well, that was selection criteria. That means examine the patient first to determine the need for the X-ray and then go ahead and prescribe it. Take it, don't just have the staff member start with a series on a patient that you already saw a year ago.

Use the fastest receptors possible and that's unfortunately, in North America we’re still at around 30 to 35% of dentists are using film. That's nowhere else in the world except—

Howard: Say that again. 

Dale: About 30 to 35% of dentists are still using X-ray film. 

Howard: 25 to 30?

Dale: 35% which means about 65 to 70% adoption of digital. 

Howard: So one-third film and two-thirds digital.

Dale: Unfortunately. If I go to—

Howard: Why is that unfortunate?

Dale: Because digital is much better and much lower dose and you can do things with it and it doesn't have any chemical processing. I mean, go to the Learn Digital site and you'll see why digital's better. I've been doing that since 1989. 

The next thing is with the collimation of the beam. Now we taught people this in dental school. We actually learned rectangular collimation on the tube, on the extra tube. I brought one to your office about three years ago. That was the little device that you can attach, greenlights come up.

Howard: I still have the picture.

Dale: True image. So do I, I brought it on a drive for Ryan. But nobody does this and the reason they don't is because they think that their dental assistant or hygienist can't actually hit the image receptor with anything but a big round cone and that's not true. You can reduce 60% of the exposure, the skin surface exposure for every image that you take to a patient just by using rectangular collimation. That's a huge dose reduction and again, dental doses are low, but they still factor into everything. 

One of the things that's interesting, I dug this out for a grant proposal years ago. 2011, dentists took $750 million bitewing X-rays. 

Howard: 2007?

Dale: No, ’11. 

Howard: 2011 in USA?

Dale: In the USA.

Howard: In the USA, took how many? 

Dale: They took $750 million, we'll say dental X-rays. You know that that number now has got to be over a billion, right? Well, think about this. How many retakes happened in an office? The numbers that I could fair it out were 10 to 13% retakes. The ones we know about. That means there's hundred million unnecessary dental X-rays taken every year in the United States.

Well, by collimating and using the device that we showed you that has the magnet that links the receptor to the tube head, you reduce retakes tremendously. It’s hard to get a retake when the receptors linked physically to the tube head. Anyway and there's other devices online in that Image Gently campaign, if you go through the dental professional part, they'll show you.

Child size exposure time, I don't know in your office, but I've been in offices where the next one is the same as the previous because they forget to change the actual exposure factors. So it's pay more attention to kids when they're in your chair and reduce the exposure time because they don't need the same amount of time as an adult, you and I with our thick heads. 

Then we get to the cone beam only when necessary and thyroid collar is a given. We all do thyroid collars on kids.

Howard: Yeah, but what percent don't use thyroid collars?

Dale:  I don't know, but nobody should not use thyroid collar. 

Howard: But back to your chart. 

Dale: Yeah, go ahead. 

Howard: Number five use cone beam only when necessary. So what are your thoughts of endodontist who when the assistant seats the patient, it's standard of care to get a cone beam of that molar an orthodontist before even sees the patient when they do the work-up, it's a cone beam on a 100% of all patients. I mean, you see that you know it's out there.

Dale: Yeah and not every patient is the same and not every protocol or procedure is the same. Let's take the endodontist first. I have no problem with endodontists doing cone beam on every case. Why? You and I send them the difficult cases. Endodontists have failures. Why? Because they get difficult cases, right.So what happens is they need more imaging data at the frontend in order to have a successful retreat or to actually treat the patient that has an odd shaped canal or multiple canals. So I don't have a problem with that because most endodontic procedures are done on adults. Correct? Okay. Well, adult thyroid is very stable. I mean it's not like a child's thyroid that's developing. So for endodontists, I'm in the camp that says, yeah, if you get the information that makes you a better dentist and helps you with a better clinical decision and treatment endodontically, I'm absolutely for it. So that's my opinion. 

On the orthodontic side, it's kind of an interesting scenario because the doses are so low. If you totaled up cephalometric-panoramic (00:16:18 unclear) series in order to do an orthodontic assessment along with your models and visual exam, probably that dose is going to be higher than a typical cone beam dose, not then a medical CT. I mean, in the implant industry, lots of people said, “Oh, I use medical CT to get my implant measurements” and it's like, “Well, you don't need to now.” That should be verboten now. Nobody should be sending people to a hospital to get conventional CT with high dose just to do an implant measurement. Cone beam, that's a perfect example for that. But back to the ortho, some schools based on the information that came out and you remember the article, it was a New York times article. A guy named Walt Bogdanich who wrote an article and said—

Howard: Can you find that, Ryan? New York Times, Walt?

Dale: Bogdanich. He was one of the two authors of the article.

Howard Can you spell Bogdanich?

Dale: B-O-G-D-A-N-I-C-H, I think. Bogdanich or might even be Bogdanovich. You’ll have to look it up. But anyway, it came out in the New York Times and it said that orthodontists were frying kids. Basically, they're taking all these CATs and that was the machine at the time that a lot of the data came from and it was a large field of view and you could kick the KV and MA up really high. The native capture at an iCAT, the KV was a hundred and twenty which is higher than all dental procedures for sure. But the MA, which is more important, was way up at twenty-four or forty-eight MA. Well, that's medical grade. That's why their images look so good, it takes X-ray photons to make images. You could dial it back, though. 

If you had a child in there and you were doing the assessment orthodontically, you could dial it back to 12 MA which is again, right in the range of all these other machines so that dentists would now have to learn, “Okay, when do I use high KV, high MA technique versus lower KV, low MA technique?” And dentists don't want that dentist in your office, my office, we don't want to keep it simple, push the button, make it happen, can't do that anymore. You really have to think about who's in the chair. 

If you put Winona Ryder in a chair to take a cone beam and you put some big linebacker from the Arizona Cardinals, they're not going to come out the same just at the same exposure factors. So and because it's not just a single image, it's a set of data and you're gathering a lot more information by a CT like mode. You got to think more about planning your X-ray, study, your radiographic study. 

Howard: Ryan, somebody Winona Ryder. I've heard the name. Who the hell's Winona Ryder?

Dale: He needs to get out more, doesn’t he?

Howard: Is she a country music singer? 

Dale: No, she's an actress. Black Swan, I’m trying to think of some of the others.

Howard: I want to go completely off subject because I have the most—

Dale: Can I stick to the cone beam for just a second?

Howard: Oh, absolutely. Feel free to always tell me to shut the hell up now. 

Dale: No, no, I will not do that. 

One of the things that I think is very timely is that dentists get these machines and the first thing they do is these images are great. The second thing is what am I looking at? Because they don't know what they're looking at. So what I did is myself and a partner of mine who's still in academia, we developed a software and it was for reporting what was in your scan. It's called Easy Riter and Riter is spelled R-I-T-E-R.

Howard: Wasn't that a movie? 

Dale: No, that was Easy Rider. 

Howard: Why didn’t you go with easy rider?

Dale: Because it's a trademark and if you type that in your browser, you're going to go to places you don't want to go. 

Howard: Which is why England drop oral cancer and went to mouth cancer. Because if you put oral in Google, you're never going to find anything with dentistry and seriously, that's why they did that and they think the United States should start calling it mouth cancer. 

Dale: Well, they've always tried to tell us what they think we should do.

Howard: Good one. 

Dale: All right. I'm a radiologist. When I dictate something, a report, it's templated. I look at anatomic areas in your head and neck scan, the same ones every time. Paranasal sinuses, nasal cavity, airway, temporomandibular joint, cervical spine and osseous, dental and other. The other is for the things that dentists didn't anticipate that could come back to bite them. 

Howard: Like carotid artery calcification?

Dale: And others. By the way, just as an aside, there aren’t just calcifications in the neck and they're not just a few sclerotic plaques in the intimal layers. The biggest population of people that have calcifications in their arteries are diabetics and the diabetics get them in the medial layer, the muscular layer. When their kidneys shut down and all that small vasculature goes to pot, they can't get the demand so they get amputated limbs, they get foot ulcers, they get real problems. They get problems in their periodontium because the small vasculature is compromised. Well, I see more plaques and they’re circumferential, they’re around the artery. 

When you look at them, when you see them in the cone beam, sometimes you have to do a little image processing to tweak it out and they go up and down the arterial wall and it's not inside the layer where they're throwing all the lipids, spares and all those things at people. It's actually in the medial layer and you can't get at that layer. So those people are going to lose limbs down the road. So I see all kinds of that stuff in the cone beam scans so we'll back the truck up. 

So in those anatomic areas, I say the same things all the time. My statements in the report are very comparable because I see the same things all the time except for the recommendations and stuff in the spine. We see stuff in the spinal column. So when you're in, let's take a simple example. Airway, okay. Lots of interest in airway and sleep. So they're looking at the airway, they see calcifications and their bilateral and there's lots of them. They go, “What are those? Those aren't plaques.” Well, when you go in the menu tab and you get down, you'll see hyperlinks, one of the words there is (00:22:42 unclear) they click on that, a picture comes up right from my database. A description of what it is, why it's important in the citation of where I found it. So it helps your decision process and it helps you make a good document with the things in it that you see, that you didn't recognize, you learn as you go. 

So the software we're really excited about called Easy Riter. You can buy it standalone and you can get it through Dentrix. They're a connected program. We're now in that program and the company that helped make it for me, Cybermed out of Tuscan, California and Seoul, Korea, they actually have it as a module in their cone beam software. They have a third-party standard, the one I used to read my cases with and all my reports. So it's available in three different kind of. 

Howard: So they go to Easy Riter and it's actually R-I-T-E-R, so why did you not put a w?

Dale Because that was also taken.

Howard: So think of Easy Rider the movie then go to the easy rider, the word then go to easy. Mnemonic device. So Easy Riter, R-I-T-E-R and this simple program was developed by a radiologist and a pathologist to help clinicians generate simple, precise, descriptive reports for their records, their patients and the referrals by now. How much is it?

Dale: At least? I think it sold for either $495 or $595. Two copies, one for where you work on your workstation with your machine and one for a laptop because you and I know we all take work home. 

Howard: So you got to buy two copies? 

Dale: Nope. Just one.

Howard: For $495 USD. Can they pay 495 Canadian throughout north?

Dale: No.

Howard: Oh, come on. you're not going to give the Canadians a break?

Dale: I think it ended up being $630 or something like that because I've seen a couple orders from up there. Actually, I go to the University of Toronto once a year to teach a small field of view cone beam course. It's thirty hours and I think that should be done by every manufacturer and if you're listening out there, I think that's what needs to be done. I do a two-and-a-half-day program for Toronto every year because the dentist in Ontario can't even buy a machine until they've had thirty hours of university-based CE. Then they get a certificate from the Royal College that allows them to buy the machine. Now think of that if we had to do that in the US. You have to have all this education before you could even be allowed to buy the machine. I don't think it would go over very well, but there's four states looking at it. You ready for this? Michigan, Wisconsin, California and Washington.

Howard: Michigan, Wisconsin, California and Washington. Washington, state of Washington?

Dale: State of Washington.

Howard: Now California, I believe because they'll do anything Canada does. They're very high regulation but why Michigan, Wisconsin and the state of Washington?

Dale: I think they're all good-looking at that model. Michigan. I mean, that's where Blue Cross Delta dental came out of right into Ontario. I mean, we all thought that and—

Howard: That's where Blue Cross, Blue Shield?

Dale: With the entry point into the Canadian market was the big Delta Dental in Michigan. 

Howard: Oh, really? 

Dale: Yeah, that was way back when I was practicing dentistry in the late seventies.

Howard: God, Delta started in 1948 and this is 2018. You've had algebra. So eight by eight by zero, four from eleven would be seventy years old. Gosh, dang, that's amazing! 

Did you ever see the movie Easy Rider? 

Dale: Oh, I did. 

Howard: Dennis Hopper. 

So you mentioned sleep medicine. Again, on that, do you think cone beam is standard of care for sleep medicine? 

Dale: I never used the term standard of care because I do a lot of expert witness stuff, mostly related to—

Howard: How come you can't get one lawyer to agree on the definition of standard of care?

Dale: We have adversarial law system and that's what you want to have a good defense if you've done something that's been negligent. First of all, we shouldn't do anything that's been negligent, but if that happened or if the patient and/or someone claimed that that happened, you want the best legal.

Howard: Back to that standard of care. I mean, you're always hearing that like okay, we’ll go to the more.

Dale: No, no, I'll stay with sleep. 

Howard: Okay, stay with sleep but then do implants?

Dale: I think it will become standard of care, but what do you mean by standard of care? Some doctors think that they can treat obstructive sleep apnea patient just by going to a weekend course. You can't do that. I don't know how many devices are out there now, probably fifty plus and everybody wants to sell it to you. So of course, you go to these courses and you're not learning anything, but what they want you to know about how to use this appliance. It goes far beyond that. 

If you join any of the national organizations, they have mastership programs, just like an AGD type mastership program where they have clinical psychologists, they have other professionals that all look at sleep, ENT, otolaryngologist. So here's the deal, cone beam is a brilliant way to look at all components of the airway. Unfortunately, we all want stand up or sit down machines and the best way to determine where the airway space is compromised is in a supine machine. Well, they don't sell them anymore because that doesn't fit our paradigm. It doesn't mean it's not good to get cone beam for airway analysis because they even have programs (00:28:20 unclear) and Cybermed, both have a program where you click on points in the airway and it draws you a three-dimensional volume, colored with the red area being the narrows and it gives you the exact measurement. You affect your treatment, you bring them back to take or put the appliance in to take another cone beam and you can see if you've opened the airway. 

So again, dentists think it's only airway. It's not, it's the paranasal sinuses, the nasal cavity, all of that affects your breathing. There's what's it called? Nasal valve collapse? People that have some problems in their nasal cavity can start to take a breath and one ail will just collapse on one side so they don't; they have to get a little implant in there to open it up. So there's a lot to learn about sleep and cone beam, I think is the most effective way to look at it. So it will become the standard of care, but I don't think it is currently. 

Howard: Now take that to implants and wisdom teeth.

Dale: I've always said and you can go back to the dental clinics in North America, 2008. I wrote an article; they gave me the leftover chapter. They said we want you to write a chapter on the future of dental maxillofacial imaging like I'm supposed to predict the future. 

So what I did was I took statements manufacturers made and questions that came to me in lectures and I said, “Okay.” Someone said, “Will cone beam imaging replaced panoramic?” for instance, because you can reconstruct a pan from cone beam, right? Cone beam data and I went, “Absolutely not.” Why? Well, I haven't seen a reconstructed pan in twenty-three thousand—well, they're not all large scans, But I haven't seen one that looks as good as a two-d grayscale dimensional digital pan and a digital five to ten microsieverts. So it's a low dose, highly useful image. It'll never go away. In my humble opinion, it won't be replaced by cone beam. 

The next question was, will cone beam imaging become the standard of care for implant imaging? And I went, “Absolutely yes.” Now is it now? No. What do you mean by standard of care? Is that the standard locally standard, nationally standard or worldwide? That's what the lawyers will say. They'll say, “Well, don't you have access to journals and can't you go to a program to learn about implant imaging? Now you now it's the standard of care, that can be a very successful argument. Like you said, lawyers will argue either side and they'll do it very effectively, but I don't think you should be doing implant imaging without using cone beam data. It's just better. You can see the thickness, you can see the submandibular salivary gland fossa that you might've dropped into it because you thought you had a lot of bone there, you can figure out if you need a sinus lift or pre-surgical surgery or and trust me, you're going to love the title of this talk. I do a talk called The Rocky Horror Implant Show.

Howard: Which is the number one movie of all time. 

Dale: There you go, that’s why I stole the title.

Howard: It's been seen a hundred more times than the number two Gone with the Wind. It was Gone with the Wind and it's still in a thousand movie theaters in America right now on Friday and Saturday night. 

Dale: Well, the reason that I took that title, I've seen the movie and obviously, I grew up in that time period. But the number of implants that I see, let's take just the anterior region where I'm sure the dentist said, “Well, I can visualize and pal paid and drill my drill at the proper angle.” The number of implants that I get because I get them post. I don't get them as they're planning the implant. I get, “Hey, there's a problem here. Can you look at it?” There's some sinus problem or whatever. I look at it and there's that implant sticking out the facial bone, all big fenestration and has to be replaced because they couldn't eyeball the angle. 

I can show you case after case after case even in the bicuspid region in the maxilla because there's little concavities, there's little depressions up in there. The number that I see that have no bone over the tail-end of the implant sticking out is scary and I have thirteen expert witness cases going right now in parts of the country. I haven't seen one where the complaint was they pushed the implant out my bone and now I'm having all kinds of problems. So we're pretty good at healing and we can tolerate a lot of things, but I have seen one implant in the sinus where they blamed all kinds of things on the implant being in the sinus and dentists have to be careful. I think cone beam imaging should be the standard of care for implant. 

Howard: Well, I'll tell you what, like in our town, we need to—Ryan, will you find me? What's the name of that rhinologist? He's friends of the endodontist Jason Hales. Do you still remember him?

Ryan: No, I don’t.

Howard: Okay. 

Dale: It's not Tim Hagen, is it?

Howard: Yeah, I think that's it!

Dale: Yeah. I lectured with Tim Hagen to the Scottsdale.

Howard: Yeah, it is Tim Hagen. 

Howard: Yeah, he's great. Can you get him to come on the show? 

Dale: Oh, absolutely.

Howard: Yeah, good memory. But he talks about how as a rhinologist, he's not a big fan of sinus (00:33:47 unclear). I mean, he sees implants that have been into the sinus or failing endo and the whole sinus is white with candida fungus. Talk about that a little bit because I want you to do this. You know how there's like fat shaming and it’s like if you get breast cancer, everyone feels sorry for you. But if you get lung cancer like, “Well, you were a smoker.” I see it with all kinds of diseases. If you tell someone, “I got pancreatic cancer.” “Oh, I feel so sorry for you.” Tell us when you're bipolar. Man, you're messed up and then they run.

I think dentist bridge shame people because if you're filing and look at the words they use: Well, why would you file down two virgin teeth? What do you mean a virgin tooth? Is there a non-virgin too? How do you measure a non? I didn't see that on PornHub, two teeth screwing and when you go to a rhinologist, they're like, “Dude, you had two elephant tusk, ivory rocks to attach your little three-thousand-year-old Egyptian bridge tooth, why did you drill into my sinus?” and then they show you cases of these disasters. But if you go to the local study club and you say, “Yeah, I don't do sinus lifts, I do three year bridges,” they're like, “Dude, you're just gross.” 

So the dentist worships the god of enamel and dentin and it's all sacred and the rhinologist worships the sinus. So who's right? 

Dale: Well first of all, both professions need to remember first do no harm; we were all taught that. Dentists think they sometimes can't do any harm because they don't deal with big problems with the patient. They just deal with their, like you said, the drill and fill components. The sinus isn't an impermeable, bony boundary. I mean, stuff percolates through there all the time. It's a living, breathing space just like anything else and I think you can successfully do implant procedures by doing a sinus lift and other things if it's done in the right hands. 

I'll give you an example. I had a second molar fail finally that I had filled, I think the first time with amalgam while I was fifteen years old. I had root canal procedure done it, I've had it repaired a couple times, I never had it crowned. Finally, it fell apart. So I went to an endodontist locally who does not only microscopy, but he also does comb beam on every case. 

Howard: Which one was that? 

Dale: It's my good friend and he's been a coauthor with me. Tom McClammy, clam dog. M-C-C-L-A-M-M-Y. North Scottsdale, endodontist.

Howard: Send him over to the show. 

Dale: I would love to.

Howard: Endodontists, their endo shows is the mostly—in fact, Ryan, you know that a video you put up the other day of the oldest video of a root canal ever done from 1917? That's coming up on like three hundred thousand views on Facebook.

Dale: I love it.

Howard: It’s crazy. Did you see that video? It was the oldest root canal video ever found. Ben Johnson, the founder of Thermafil bought it in the garage selling Kentucky. But anyway.

Dale: So back to my extraction and implant. I haven't had the implant yet, but he did my extraction by the way, under rubber dam through the microscope. I mean, the most atraumatic extract. This was an upper second molar; we were going to let it heal in. He looked at it. As old men do, I needed to go to the restroom. I came back to the chair. He says, “Dude,” because he's an old guy like you and me, but he still's dude. He says, “We need to put an implant in there.” He says, “That palatal socket is perfect for” and he named the implant. 

So what does he do? He drops in an implant at the time that he does the procedure and it was like, wow, this is too cool. It's been six weeks or eight weeks now I'm going to go back for post op and I'm going to have an implant in site fifteen and he does it right. 

He’s an interesting guy, by the way. Cowboy out of Bend, Oregon, practiced for nineteen years before he went to endodontic graduate program at BU. 

Howard: Nice!

Dale: So he’s a fun guy. Still a cowboy. 

Howard: Well, I trust endodontists more that place implants because if you have a stay-at-home wife and four kids and your only tool is a hammer and you need to do eight molars a day, one every hour all day long and I send you failed root canals, you just retreat and then they fail in six months after you took $1,500 for it where they go, “Well, I did the best I could.” It’s like you're not incentivized to say “No, I think this is fractured and junk and you should pull it out.” But if you could sit there and say, “No, this isn't worth saving, let's pop it out and place an implant,” I trust you more and people say, “Well, that's really bad.” I mean, every PhD economist says incentives matter and how many hospitals take a CAT scan on every single patient that walks in there because they're going to bill Medicaid and Medicare, $6,500 and I trust those guys more. 

I want to go back to your lawsuit. So Socrates says, “The only thing that really motivates humans is greed or fear.” So if you're not greedy to do the right thing, you fear you're doing the wrong thing. You're in a dozen lawsuits, you've been doing this for a long time. When did you become a specialist in radiology? 

Dale: Long before it became a specialty. I did my post-doctoral work and post grad work in San Antonio in 1980 to 1983.

Howard: And what year was Wilhelm Roentgen? 

Dale: Roentgen, he’d discovered the X-ray in 1895, November the 8th and the reason I know that is—

Howard: November?

Dale: November 8th.

Howard: November 8th, you know the date?

Dale: My oldest son was born on November 8th and one of my grandmothers, my maternal grandmother, was born in 1895. So it’s easy for me to remember.

Howard: Wow and he died of suicide, didn't he? 

Dale; No, that was Edmund Kells.

Howard: Edmund Kells? I thought the story went that Roentgen was always taking X-rays of his hand. 

Dale: Edmund Kells. 

Howard: That was Edmund Kells?

Dale: No, Kells. Edmund Kells, K-E-L-L-S. You can look that up. 

Howard: He was the one taking X-rays of his hand?

Dale: In the United States.

Howard: And got hand cancer and the pain was so bad, he shot himself?

Dale: Well, it started with his hand and then went up his arm and finally—

Howard: Edmund. How did Roentgen die?

Dale: I have no idea.

Howard: I thought he committed suicide. 

Dale: No, you probably have been disseminating bad information for years about that. 

Howard: No, I posted the Wikipedia about that.

Dale: If it was a suicide, it wasn't from holding X-rays. I don't know how Roentgen died.

Howard: Yeah, okay. Ryan, can you search how did Wilhelm Roentgen die? He was in Germany?

Dale: He was in Germany, but I think he was Austrian by birth. 

Howard: Well, Austria and Germany, those borders. If you look at the history of Austria and Germany, many times Austria was much bigger than Germany. I mean, that was Poland. Poland is the wildest country.

Dale: Michener, you need to read Michener’s book, Poland. You know how he wrote Centennial and Hawaii and Chesapeake and read Poland. 

Howard: It's like documentary fiction.

Dale: Yeah, it's a sad story though. All the people that invaded Poland, it’s still going on. 

Howard: Well, they're in the wrong place. In the United States, people always free you've got an ocean on two sides and Canada to the north. That's like living in an apartment and then your best friend’s up in the loft. And Mexico, the culture, it's just so fits. But Poland, god dang. They are the crossroads of Germany, Russia. I mean, they’re just in the worst location and you know who has that worst location now and people always don't realize, it is China. China is surrounded by Russia, Mongolia, India, Pakistan, Vietnam. I mean, they're almost every country that touches them if they just made a—like the German Blitzkrieg couldn't make it to Beijing. 

So I mean, if the United States traded places with China, they would be ten times more military paranoid. 

Dale: I can’t see Vietnamese invading China, though.

Howard: Well, they got ninety million people and they beat us. 

Dale: Yeah but they're only right there.

Howard: But Vietnam beat the United—we lost the Vietnam war. They have ninety million people; if ninety million people, if they made a Blitzkrieg attack, they’d probably get damn far.

Dale: Well, you're still talking conventional warfare. 

Howard: Well, that's what they master. 

Dale: They would be nuked off the face of the planet and then it would carry on. Anyway, we won't go there. 

Howard: We won’t go there. But I want to go back to the fear, though. Lawsuits, you have been doing lawsuits for a long time. What generally is a dentist doing where he's going to end up with an attorney? Where it usually goes wrong.

Dale: Actually, most of the lawsuits that I've been involved, they mostly involve oral maxillofacial surgeons and one of the big areas right now, which I don't think cone beam would help actually and I know that might surprise you, is that it helps in the post-mortem when we're trying to evaluate why did they do what they did. The damage to the lingual nerve where it comes off and it can be high or low up in the posterior part of the—

Howard: Yeah, you're always afraid of the inferior alveolar nerve, but you always hit the lingual nerve. 

Dale: Well, the lingual nerve damage because as a surgeon and/or dentist, usually they do straight bur on big the bone bur and they're trying to get a trough to get some purchase in posterior part of that third molar region in the lower. They basically perforate through the plate and the lawyers all claim that's why the patient has the taste problems and altered sensations and in some cases, I think the patients being honest and in some cases, I don't think that. I think the lawyers have convinced them that all of these problems are due to that surgery. So that's one of the areas.

Implants in the sinus, I told you was another one. So if you're at the frontend, if you're entry level and you're at the frontend of your learning curve, I would always use cone beam to assess the amount of bone you have and whether you should be going into the sinus with a sinus lift or graft procedure. 

So the other areas, there aren't many areas, third molar extraction. The biggest lawsuit settlement I think in history was on damage from a third molar extraction from an oral maxillofacial surgeon and I think it was in Florida and it was someone ungodly fee like either two and a half or three and a half million dollars and that set the wheels in motion to limit judgements and penalties against that. 

So I really do think, I know I didn't answer your question directly, but I do think cone beam should be used for all lower third molar extraction. By the way, when I do 3D color reconstructions of the upper thirds, the ones we all think are easy to take out? The number that I see with nice little hooks on the roots are divergent (00:45:57 unclear), the pallet going off one way and a distal buccal or something going another making the extraction difficult is a lot greater than I thought. 

So I always make 3D reconstructed color views of impacted third molar no matter if they’re maxillary or mandibular for my clients. They get a picture of it in the report.

Howard: And I want to tell you another thing that gets you in trouble is your ego. You're pulling out a tooth and you snap off a little two, three-millimeter root tip and that root tip never, ever, ever causes a problem; you got out 95% of the tooth. The only time that little root tip will ever be a problem is if the body works out like a splinter and you had to go pick it through. But your ego says, I can't tell the patient I left a three-millimeter root tip so I'm going to get out the big five fifty-seven surgical bur and I'm going to go destroy half the socket and I'm going to get that thing out and then you do nerve damage. 

Do you agree or disagree that a broken off root tip should be like sleeping dogs sleep?

Dale: That's a good question. I don't know if I have a really precise answer for that. I'd probably, I wouldn't go digging along for it. If you can see it, if you're in the actual space then you might be able to retrieve it easily; I probably would try it. If you can't see it and you're only trying to open up and get bigger access surgically to see it. No, I probably agree with you. I probably wouldn't do it. 

I see a lot of foreign body, which would include a root tip in the maxillary sinus because that's where dentists concentrate; there's lots of other sinus spaces in there, of course. But in the maxillary sinus, a foreign body is called an antral lift. Well, I've seen lots of antral lifts, many of which are our root tips. They do cause some localized inflammatory change in some cases but yeah, you could leave those alone. 

If there's an AO defect and it's been long standing and there's changes in the sinuses and lots of mucosal thickening, alteration of the walls. Yeah, you got to repair the defect. I mean, those always have to be repaired. So it could be at the time of the repair of the defect, you could get the antral space cleaned out and maybe even the root tip along with it. But good question. 

The reason I went down that path is because your rhinologist as you called them, the otolaryngologist, when they go into the ostium. Remember the maxillary sinus, the dependent portion is where the stuff gathers up. Now you can get inflammatory change around the rest of it, but if you've got inflammatory change and/or fluids in the sinus, they go in through the ostium with a scope and like an irrigation unit and they can take out the material. They can do balloon sinuplasty, they can do a lot of things through that osteon so maybe if a root tip goes into an antral space, maybe we ought to think about referral to the otolaryngologist for a “clinical and endoscopic evaluation” to see if they can go in there and get it out through the osteon. 

Howard: But you can't because no one can say that word. I can’t say it. 

Dale: Otolaryngologist or osteon?

Howard: I call it rhinologist, is that slang?

Dale: I don't think anybody uses that term much anymore. 

Howard: What's the substitute word? What's the real?

Dale: Otolaryngologist? 

Howard: Otolaryngologist?

Dale: Yeah because they all do eye, nose and throat. ENT. I would just use an ENT doc. There’s your term.

Howard: Yeah. Roentgen died on 10 February 1923 of carcinoma of the intestine. 

Dale: There you go. 

Howard: Do you think that was caused by radiation? 

Dale: No.

Howard: I'm going to go completely off record because I have access to an amazing mind. There's a lot of dentists, I'm not talking about a lot of people sit there and—who's a big naturalist out there that people think were whack jobs in healthcare? 

I'm not talking about those guys. I'm talking about really accomplished dentists who don't even like them being exposed to their own Wifi at home and they are taking out Wifi and there's people out there now in the news media saying holding the cell phone to the head and I'm not concerned about anything my iPhone does to my head. I’m talking about what concerns me is I always keep it in my pocket. My god, I'm worried about what it does to my stones, not my brain. 

Dale: It's too late for that hour. 

Howard: I know this is a dumb question, but do you think holding an iPhone to your head all day long and sitting at a desk that has Wifi, do you think that someday going to come back and bite us?

Dale: Or looking at the computer screen because that's also? I don't know. When you look at pie charts of we'll call them radiation exposure. Radiation is a spectrum, including the stuff that's from your cell phone and your computer. They always include it as what our annual exposure is, but let me give you. I'm glad you asked me that question. 

Walking around the planet, we get three thousand, six hundred microsieverts of radiation to our body every day. Might be a little worse in Denver because you're a mile high and you've got cosmic rays and stuff. 55% of that comes from radon in the rocks.

Howard: Coming from the ground up?

Dale: Yeah and not only radon in and like exposure in air, radon in our foods. If you grow plants in soil that have rocks nearby, there may be an isotope decays that actually gets into the water supply that actually gets into your lettuce. So you might be eating organically very well and getting rid of pesticides, but you ain't getting rid of the radon. It's just there and if it were so bad and if it were carcinogenic, why did it take a meteor to kill the dinosaurs? Why are we still on the planet with everyone not having cancer? I mean, 55% of our annual dose comes from rocks. 

When I was in Indiana, I had to have radon—and many of your listeners out there, lot of states have to have radon testing in their basements to get the levels down because they've “determined a level that they think is unsafe.” Well, that's just part of it. I mean when you look at the cell phones and all the other things, thirty-six hundred microsieverts a year.

Back to the conventional CT number at two thousand, one hundred microsieverts, you can imagine then why they're concerned about kids because they get two-thirds of their annual walking around the planet dose from one medical CT. 

Now just as much harm can come to a patient from not getting an X-ray procedure. Do you know what I mean? If you have something that you need good data to affect the treatment with, you need good data and if that's a tumor in the brain or a tumor elsewhere in the body, you'll need CT. 

Lucky for us, we don't see much of that in the head and neck region except soft tissue cancers like oral cancers and all the mucosal things so that we don't really need radiology for that. Our radiographic procedures are probably the lowest of any professional and probably the safest, but it doesn't mean we can't ignore the potential for some harm.

Howard: Well, that dinosaur stuff. My Mom is the most intense catholic I've ever met and my two older sisters went straight into the nunnery after school and my Mom would tell you that from Adam to Abraham was two thousand years according to the Hebrew text of Genesis 5 and that the earth is only six thousand years old. So you're part of a conspiracy.

Dale: Yes, I am. 

Howard: Well, I want to go back to another thing that's very confusing right here in Arizona. Those holistic dentists I mean they got eight years of college, they’re a dentist, they believe that one of the most important things is to go get ten minutes of sunlight every day for your vitamin D3 to get thirty, forty thousand units and there's a lot of really smart people saying how beneficial that is and there's a lot of people showing that when you live in Scandinavia, when you live in Denmark, Copenhagen, all winter where 3Shape is or Helsinki, Finland where Planmeca is that that's really bad. So the holistic dentists, the holistic physicians are saying that then they go to their dermatologist, they say, “Oh my god, right by your toothbrush, have you brushed your teeth, you need to put sunscreen everywhere and you need to not go out in the sun between 11:00 and 4:00 PM in Arizona and you need to go hide in the basement.” So the consumer really gets mixed information. So how would Dale the radiologist, how would you opine because you live in the desert?

Dale: Yes in actual fact, I had a basal cell carcinoma taken off my left temple about a year and a half after I moved here. But the thing is, they're finding out now research, it's not just this exposure we're getting now. It's the exposure we had over a lifetime to your skin cells when you went and laid on the beach and wherever you laid on the beach as a kid and didn't put sunscreen on and got burnt to a crisp and then had to have all kinds of bombs and things to make it feel better. But you went out there again to get that tan. That’s still going to come around. 

Howard: So you think the cancer in your fifties and sixties and seventies is the stuff you did when you were in your tens and twenties? 

Dale: Some of it is, some of it is just called immunosenescence where basically our cells run out of division time. There’s program cell death in our bodies. In other words, from the first divisions to the last divisions, it's already there. So that's why you have seen genetics and immunology taking over all the cancer treatment and being such a huge part of everybody's disease processes. Your genes if they're good, they're good; if they're bad, they're bad and unfortunately, you can't change that (00:56:18 unclear).

Howard: Oh, you can. No, go to Nordstrom’s; they sell jeans everywhere. The best jeans I have, I bought at Nordstrom's. 

Dale: But I mean, that's the whole thing. I mean, I live in the desert. I'm quite happy knowing that I'll be long gone before the cockroaches and the scorpions; they're going to be around a lot longer than we are because they adapted. 

Howard: Have you ever found a scorpion as big as the one I showed you, the picture I showed you this morning?

Dale: No and I saw that and the two inchers don't disturb me. It's the little bitty ones that have the venom that's ... so the ones you don’t see.

Howard: Right, that's common. Dale knows his scorpions, it's the small ones that get you. I obviously been stung twice. Once I opened up the Sunday paper and it flipped right on my forearm. I want to switch to a whole nother subject. Are you okay with time or you need to run?

Dale: No, I’m okay.

Howard: Now I'm going to open up a huge can of worms: TMJ. Some people think it's psychosomatic, some people think it's stress. What are you seeing on cone beam on TMJ? Are you finding?

Dale: Well, first of all, you're like every other dentist and patient: I've got TMJ. What do you mean by that? I got two of them, I got two temporomandibular joints, right? A joint is a joint is a joint. This happens to be a loaded joint, it's not weight bearing like a knee, but it has load on it and we use it a lot. Look at how we're chatting and drinking and swallowing and whatever. So I see a lot of osteoarthritic changes in the joints and not rheumatoid; I've seen very few rheumatoid, arthritic patients because they go to the rheumatologists and their physician first. But I've seen really, really ugly changes, gross remodeling in temporomandibular joints, condylar head and the fossa with absolutely no symptomatology. I've seen small surface erosions at the frontend of the disorder, little remodeling, subchondral cyst formation where the patient is painful. 

So first of all, there's bone changes we see those. I mean, cone beam is the best for that. I can make a 3D color image of the—I can actually do an AVI video, fly around the condylar head in the software that I use. That is that Cybermed software. 

By the way, back to airway. I can do it down your throat, too so when I see lumps in the throat, when I see a mass effect that's closing the airway and I know it's not tonsils or adenoids, I make an AVI video to put in the client's folder. They open it up for the patients, say we found a mass, that's why you're having difficulty swallowing and here it is. You need to see your otolaryngologist. Your ENT doc. So back to the TM joint. Not all joint disorders are bone. They're not arthritidis or some of the other connective tissue disorders. I mean, I've seen psoriasis up there, I've seen psoriatic TM joint, I've seen patients that have what we call a mixed connective tissue disorder where they have Sjögren's and psoriatic changes. I've seen those kinds of joints, but also we have the soft tissue components. The disc and the elements there and the inflammatory changes that can occur with trauma without bone change. 

By the way, you've heard the hierarchy of—disc displacement was the old term, the term’s got (00:59:54 unclear) internal derangement was an old term. Disc displacement with or without reduction and/or perforation, you know where that classification came from? It came from three guys, Charles Greene, Daniel Laskin and one other very famous oral maxillofacial surgeon, it might have been Frank Dalvik. When they told me the story, it was we came up with that with beers around the pool.

Howard: Really.

Dale: Well they were into the joint, that's when they were treating joints back then by open surgery and putting in Pro Plas and all that stuff and they had to come up with anterior displacement with reduction, without reduction, with perforation. So they came up with that classification having beers around the pool, three smart guys.Back to the only way you can look currently at soft tissue in the joint is either by arthroscopy to see if there's a displacement of the disc and they don't all just go anterior, they can go medial, lateral. The disc can go in a lot of different places, but MR, magnetic resonance imaging, is really the only current way to look and see where the position of the disc is. So if you've ruled out bone changes and you've ruled out myofascial pain and the things that go along, headache and the bruxism clenching and you think it's a disc problem, you need to get MR. You need to get magnetic resonance imaging to see the disc. Now, having said that, and I can't tell you much, but one of my oldest, dearest friends who's Italian living back in Verona now that used to be the head physicists for GenDx. He's working with a company right now that are working on a soft tissue cone beam machine so it's going to be able to tweak.

Howard: Would it be an MRI?

Dale: It's not an MRI, it's cone beam.

Howard: Will MRIs ever come to dentistry or is that?

Dale: Well, they already are in dentistry. You can order, I mean. 

Howard: But I mean the MRI is a huge. 

Dale: It's not going to be in your office.

Howard: It’s not going to be? They're never going to? Well, they say everything always over the years will go faster, easier, higher quality, lower costs and miniature. People always forget the miniature. Do you think the MRI will ever be miniaturized to be in a dental office? 

Dale: Well, it already is to some extent, but what they do is they do surface coils to do that. So they basically don't put your whole head in the machine, but you still go into the machine, but you have a different size coil so that it only captures your head region very elegantly, we'll say. So they do have those units, but you still have to have a magnet to generate. 

I mean, you know what you're doing, right? You're taking the excess protons that are spinning and you're not going to move over and then as they return, they give off a little radio frequency. Well, you can't make a small magnet do that you have to have a big magnet. I mean, these MRI machines use the energy of the whole small office building. 

Howard: Did you see the lawsuit GE just had to pay an endo? 

Dale: No. 

Howard: They had a GE MRI imaging center and some boy or someone walked through there and he had a metal instrument. He was sucked into the machine so fast. I forgot what he had on him, but he was sucked into the machine so fast he broke his neck and died.

Ryan, did I ever tell you about my favorite MRI? Your little brother. I mean, your oldest brother, Eric was like one and he fell and he hit his head really hard and we rushed him to Chandler and the doctor said, “I got to get an MRI of this,” but Eric was very upset and everything and he said, “The only way we to do it is if you laid in there and held him.”

So as I laid down there and got him all comfortable and got them to nurse my finger and he was nursing my finger and we did the MRI and I was looking at his skull. So adorable but back then, that was 1990 so I didn't get a copy of anything.

Are you hurting for time? 

Dale: No, I’m okay.

Howard: This is Dentistry Uncensored. They want to know what machine you recommend. Today is CDA at Anaheim—

Dale: I’ll be there tomorrow. I’m actually talking to a couple of manufacturers.

Howard: How many machines are there for sale? She's twenty-five, she just got out of school, she's going to open up office, she's got to make this just take it off her list. 

It’s like when I talk to an oral surgeon like how many implant systems were at (01:04:25 unclear)? There were a hundred and seventy-five systems. So my homies just want to say cut the bullshit, I don't want you to evaluate hundred and seventy-five implants systems. Which one do you use? Which cone beam would you use? 

Dale: Well, I'm glad you phrased it like that because first of all I don't do that. Obviously, I read the scan data and make reports so I don't own a machine. But I get to see the data from all the different machines and the question you asked me is just like I get it when I lecture for a day and a half or whatever. I heard what you said about all those machines, but if you had to buy one, which one would it be? I'm not going to do that because I don't practice like you, you don't practice like Bob or Shirley. You have to sit down and I’ll give you a couple things. One I did in your number sixteen podcast that we did. You have to do an assessment in your office and I actually have a tool on the doctorconebeam.com site. There is an assessment tool. You can fill out a two-page questionnaire which will help us get—

Howard: Which website is that because you have Learn Digital, Doctor Cone Beam, Easy Riter. 

Dale: No, that's on doctorconedeam.com.

Howard: So if you go to doctorconebeam.com, you said there is—

Dale: An assessment tool.

Howard: And where would that be under?

Dale: I think it’s under Consultation.

Howard: Let Dr. Miles help you with due diligence and decision about which CBCT machine is right for you. After completing the assessment form, you can contact Dr. Miles for an in-office consultation to help you get the best cone beam technology for the application you're considering. So you asked for their name, city, etcetera. So can I read the questions? 

Dale: Yeah, sure. Better yet send everybody there. I don’t need the hits, but they can go there and take a look and see it. 

Howard: Well, my goal is that they can make decisions faster, easier, higher quality. That's all I'm trying to do here and it's my favorite hobby and you know what's so romantic about this hobby is when I was little kid in Kansas growing up at the farm, it was like when people talk about the internet, they don't know what they're talking about. 

The internet used to be when I grew up, those farmers out in the middle of nowhere, they'd go into their barn and they'd have those ham radios and some of those ham radios I mean, they could talk a thousand miles away and they would tell the wife, “We’re talking about how to grow corn and wheat.” They were talking about baseball and movies and I can still remember being this tall, what David Hoff out on the rock in our ranch in Fort Scott, Kansas. We were mesmerized by ham radios. So this is my ham radio. 

Dale: He just dated himself.

Howard: I'm thirty-two. So which dental distributors supplies your office and supports your current dental technology? Which digital imaging products you currently own? Proposed dental applications, CBCT level of understanding and by the way, the level of understanding you might think you understand it. So there's three dentists in my office, right? Do you know how many times three really smart dentists looked at a CBCT and were just like, “What's that?” and we're all like, “I have no idea.” I mean, it looks like I'm looking at the Galileo images of deep space. 

Dale: That’s why there's oral maxillofacial radiologists, we know what we're looking at. 

Howard: Potential impediments to purchase costs, lack of knowledge so if they go there and fill this out and submit it to you, you're going to reply with some answers?

Dale: Yeah, most times and I have to make—this is an admission publicly that I get very few of those. I'm very bad at answering them, but I do eventually get around to picking up the phone and asking several questions. 

What I would love to do, if it worked out the way I thought it should work out, is those people that then in earnest want me to come in and kind of assess the status of their office, I would go there and I actually had someone from the Phoenix area send me one about a month ago and that tells you how quickly I've responded because I haven't responded to him yet. So I owe that doctor an apology.

Also, you know Michael Gelb? 

Howard: Yes. 

Dale: Well, Michael Gelb was at a course I did in Suffern, New York about a month ago and he has sent me a filled-in part of that assessment tool and I haven't called him back and that's almost been the same amount of time, but I get around to it. Sometimes they'll then tweak me with a second follow-up email and say, “Hey, I sent you this and I haven't heard” and I promise to do a better job on those. But even just filling out the assessment tool by themselves makes them start thinking it is the first part of their due diligence. 

In that first podcast that we talked about, I said, “Dentists don't realize how much money they make doing X-ray services.” Do you remember that? And I said and what I do is when I call them back, I'll say to them, “You need to sit down with your office manager, run a productivity report only for the X-ray services done in your office” and I don't care if you only did one cephalometric in the last year. Put all the codes in, the CDT codes, the CPT codes for the procedures, run the numbers, look at it and then go, oh my god, look at all the money I make off X-rays and I'm a radiologist. I'm not telling you to take X-ray to make money, it just happens. We need that data to make clinical decisions. 

When you look at it and then you look at the number of tasks that you can do in your office where cone beam will help you, then you get a better idea of what kind of machine you need. 

The manufacturer piece is I asked him, where did you hear about this or are you working with a distributor because you want service after sale and the only way to get that is to talk to your rep first, look at the products they offer, see if it's a good fit for your practice. So when you asked me the question wayback ten minutes ago, what machine would I recommend? It's practitioner dependent and that's why the assessment tool. Now I could sit here and I might do this, I might put an article, I posted little articles periodically, some of the—

Howard: Put an article in Dentaltown magazine! We go to a hundred and twenty-five thousand dentists.

Dale: I’ve had two in there for you.

Howard: I know but the reason I always try to get more is because I know you're a humble guy, but all the smartest people I know consider you the world authority, number one in CBCT.

Dale: You heard it here. 

Howard: No, I know you're a humble guy, but I don't know anybody who thinks there's someone other than you. I mean, it's kind of like Stanley Melamed with anesthesia and you with CBCT. 

Dale: Yeah, I appreciate that. 

Howard: Well, I mean, you know it. 

Dale: Well, here's the article I think I might do. I think I might send out an assessment tool to all my clients and of course, they're going to give me their feedback based on their ownership of the machine, but I would like to rank them. Here's my first tier products, here's my second tier, here's the third tier. Manufacturers won't like that but it's how we have to sort of understand. I don't work for any of them. 

Howard: Yeah. I mean, the smart ones. I'll give you a story about the late Bob Ipsen. You remember Bob Ipsen, founder of DenMat? 

Dale: Yeah.

Howard: He called me one time and he was so upset because somebody said something on Dentaltown and he was already to sue me and this and that. I said, “Bob,” I said, “First of all, sue me” because it's David and Goliath. I said, “Nobody could do anything better for my career than have a big little monster DenMat guy with $100,000,000 sue little fat Howie, because some dentist was sharing what he thought. And I said, “So please”—In fact, I said, “If you sue me, I'm going to go to the judge and I wouldn't even answer questions because I want to be thrown in jail just to get the picture of me behind bars by allowing you free speech.” Free speech to dentists.

I said, “But Bob, if you had a brain. You do have a private jet.” Because whenever he'd want to have lunch with me, he'd send over a private jet, fly me back to Santa Maria and we'd have lunch at the airport and then he’d fly me back home. I said, “That guy is in San Diego. Send your jet down there, pick him up, fly him back there and try to understand why he hates your product.” “Oh, I want to sue.” I talked him into it. He flew him down there. It was love at first sight. Two passionate dentists colliding. Now they saw eye to eye and so when manufacturer—

Dale: Kind of what Trump is doing with Kim Jong Un. Oh never mind, I won't.

Howard: But so like dental manufacturers, the smartest dental manufacturers go to Dentaltown where a quarter million dentists have posted five million times like Sonomed. You do a search on Sonomed, there's five pages of threads. Not one person from Sonomed has ever replied to anything. I'm just like, but they want to buy ads in dental magazines and then there's companies like, gosh, other ones were oh what's the one out of? Um, what's Periodent? Prospodent? Pulpdent? Is it Pulpdent?

Dale: What’s the question here? 

Howard: No, I'm trying to get the name of the company if I can find it. Yeah, Pulpdent and every time someone says something about Pulpdent, Larry Clark gets in there and explains his point of view, listens to them and how many townies have posted on Dentaltown, “Larry, can we come visit your manufacturer?” So they'll go down there and Larry will get four or five townies at a time and spend the whole day telling them why they make the products they do. 

Dan Fischer of Ultradent is another one. If you tell Dan Fischer, “Dan, I don't agree with anything you say about this product.” He's like, “Wow, wow, tell me, tell me why” and then the end. So manufacturers should listen to you and say, “Okay, well this is 2018, this is version 3.0 but where should version 4.0, 5.0?” So if you don’t like constructive criticism. I mean I'd take construct criticism. Well, one time some girl called me a short fat, bald idiot and you're talking about joint internal derangement? She said I had brain internal derangement. So you got three websites again, not to confuse them. What's the difference between doctorconebeam.com, Easy Riter with an r, no w and Learn Digital ? You haven't said anything really about Learn Digital. 

Dale: Learn Digital was my initial website; I actually started it in 2000. I'd actually been lecturing and educating our colleagues about digital imaging since ‘91 and I thought, I'm answering the same questions all the time, (01:16:15 unclear) content. So I started to Learn Digital and that was really to help focus people on the transition from film to solid state detector imaging and there's still a lot of good content on there especially because there's still 35% of dentists in the US that don't use digital and there's panoramic stuff. There's all kinds of things on there; there's dose information, there's links to certain sites. 

Easy Riter was basically because we had an arrangement with CyberMed to develop the product, we wanted a standalone version for the doc who didn't want to have, they already bought a machine, they had software they liked with the machine, but they didn't have a good reporting sort of tool. So we developed that reporting and clinical decision-making tool so that's a separate site.

Doctor Cone Beam is the one that gets the most traffic right now. Of course, that's why I'm sitting here talking to you because Doctor Cone Beam has articles, my lectures schedule, the decision support sort of assessment tool. It has videos; I probably have sixteen videos on that site. They're all two to five minutes long. It mostly for dentists, although there are some that are pertinent to patients, too. Dentists could download it and show it to a patient about why they're using cone beam, why they're suggesting that the patient have it so there's a lot of good content on there. There's at least thirty articles. 

It also saves me from when I lecture of having to send a handout because I don't bring it. I want people to listen. I want people to really focus on what I'm trying to educate them in and then to pad out or to fill out the questions that they might have left with. They can go to the website and download the articles from there. 

Howard: I'm still going to go back because I'm just that kind of a jerk. But do you have a short list of CBCTs that you like? Are there any brands that you trust? 

Dale: Yeah, in full disclosure, three or four years, I did some consulting for Planmeca so they've always been high on my list. I had them in five different dental schools and the reason I picked that technology was it worked. They're born engineers, like you said, they spent ten months of the year in darkness so they're all big—

Howard: And 3Shape over in Copenhagen, Denmark, they're walking away with the oral scanning before.

Dale: Of course.

Howard: Have you been to their headquarters? 

Dale: No, I have never been there. 

Howard: Have you been to Helsinki, Finland? 

Dale: Yes, I have.

Howard: But I mean those are intense cultures. I mean, even the dentist. You go have lunch with dentists and they'll say, “Well, in the winter I worked 7:00 to 7:00 Monday through Saturday” and I’m like, “What?” But anyway Planmeca. 

Dale: Planmeca, I still think that the imaging sciences, ICAT is a very good machine even though—and they are the biggest, by the way. They have the most sales anywhere in the world. The reason their image quality is so good is that they basically use a higher MA technique to capture. So you need extra photons to make an image. 

What I don't like, and I don't know if they still do this, but all of the manufacturers that basically sold you a maintenance agreement contract with your machine, I have a problem with. I don't know how far to go with this, but I would demand to know what I'm getting for that contract. If I'm paying $6,000 a year on top of the machine cost, what am I going to get for it? Where's my schedule of maintenance? When are you going to upgrade my software? The things that they promise haven't been delivered in many cases. It's just like the razor blade, they sell the maintenance contract, but it's a protection thing and half the time no one gets the value of—

Howard: Who's the president and CEO of ICAT. 

Dale: Currently, I don't know. I knew the principles that started the company, but I don't know the CEO. It's because Danaher took over.

Howard: Oh, Danaher the largest company in dentistry; nineteen billion in sales. I mean, Ivoclar only does a billion, the 3M Dental divisions a billion.

Dale: One of the machines and I'm having a senior moment here because the two companies, Instrumentarium and Soredex reformed the original company called PaloDex and I think basically, they are part of that sort of Scandinavian group that makes good machines. So everybody got kind of rolled into one family, like the Henry Schein Danaher family of machines. They're all good machines. 

Howard: Oh, Danaher's not related to Henry Schein. Danaher's out of Washington, DC. 

Dale: Yeah, I know. One has controlling share of the other, though so.

Howard: One has controlling share of the other? Danaher has controlling share of Schein? 

Dale: It might be the other way around.

Howard: Schein has a controlling share of Danaher on stock?

Dale: I don't know if on stock, but in the terms of the decisions made within the company, the decision-making still rests primarily with Schein. 

Howard: What does Danaher Schein what CBCTs do they? 

Dale: Well, let me back up the truck here. The next one I would put on the list would be J. Morita. 

Howard: So Planmeca, ICAT, J. Morita.

Dale: To me, those are the top tier.

Howard: So the top tier is Planmeca, ICAT and J. Morita, but what were you saying about Instrumentarium?

Dale: Well, I think they're selling it under the KaVo brand, though. Now what's happened is with all these roll-ups and other things and acquisitions within the different families of companies, I think the Instrumentarium used to make a cone beam machine and I want to say it's the OP 300 or whatever the designation was and—

Howard: Ryan, can you Google search the Instrumentarium OP 300? But you think Instrumentarium might have merged with who else? 

Dale: KaVo. They're selling it in the US now under the KaVo name, I think.

Howard: Which is owned by Danaher.

Dale: And then there's other machines coming to the market, for instance, Suni Imaging, they make the intraoral sensors. They've introduced a cone beam machine. It's made in Japan. I forget who makes it, but I think it'll be a good machine. 

Panoramic Corporation, the guys that internet marketed a panoramic machine? They are introducing a cone beam machine to the marketplace as well. 

I didn't mention the Korean company that says they're number one in the world. They have a good machine as well. It'll come to me in a second. I don't do a lot with those machines. 

Carestream, I used to see a lot of advertising, print advertising, things through your internet almost on a weekly basis from Carestream about their machine. I'm not seeing as much anymore. Didn't they get sold? Weren't they sold yet again? 

Howard: Carestream, yeah. I had Softdent for thirty years. I switched over to Dental, I couldn't even follow who owned. 

Dale: So like what I want to sort of stress is that all the machines are good, some are better than others. I don't think there's a bad machine in the marketplace. There used to be and that was the original Galileo's. I really did not like that machine and I got into discussions in problems with Sirona about that, but that happens. I have my opinion about the machines because I see the data. 

Howard: What do you think of their merger and acquisition with Dentsply? 

Dale: I haven't seen the results of it yet. It's been over a year, right and what's happening? I mean. 

Howard: Well, a lot of resignations on that merger, right? Top three dogs. 

Dale: Yeah, initially. 

Howard: So was there anything I wasn't smart enough to ask? 

Dale: No, I think you've just about sucked my brain dry here this morning.

Howard: Seriously, it's always just a huge honor when you do an online CE course or write an article for us. I mean, to have the number one dog in this space grace our presentation. I'm dead serious. 

When you're out with dentists and you're lecturing and eating lunch and everything, when it comes to anesthesia, they only quote Malamed; when it comes to CBCT, they only quote you and you have the most views and likes on our Dentaltown magazine. 

Back in the day when I started the magazine, editorial was a gut feeling. Well, now we have a quarter million dentists on Dentaltown so when we put up a digital magazine, we know which ones are collect, which ones aren't collect. So like if I'm going to build an article on a root canal, well, I've already been publishing articles on root canals. I mean, we started Dentaltown magazine 1994 and the website and it was March 17th, 1999 on St. Patrick’s day because I'm a 100% Irish. So I know who reads it. 

So there's a lot of people who might think they're all that and a bag of chips and I'll say, “Actually in your space the top three guys are this guy” and in CBCT, it is you, buddy and it is just a huge honor that you would leave where—he lives where all the rich and famous people live in short hills and he came out here to Phoenix where they're poor and we have scorpions on the wall.

By the way, you're number one in CBCT. You know what I'm number one in? I can do dentistry—

Dale: With a bottle of water on your head.

Howard: No, I can do dentistry underwater.

Dale: Cute.

Howard: Oh yeah, I did that. I took a picture of it and put it on social media. I have proof.

Dale: I think you own social media. Every time I go on Google Plus, there's nobody else on that page but him.

Howard: I think we're so old we're the only two dentists on Google Plus. I think all the millennials are like “Google Plus, didn’t they shut that down before Snapchat and Instagram?”

Dale: And then there was what Google chat room or Google whatever and a couple of people interviewed me on that, but it was like it just didn't fly. 

Howard: Well, Google is, it's amazing how they've let more major businesses slip through their fingers. I mean, god, even when Facebook started, they could even bought that for us. Sing a song and a dance. Let me show you my.

Dale: Your underwater picture?

Howard: I don't think I can even find it but anyway, seriously, I know. How long did it take you to drive down here? 

Dale: About thirty-five to forty minutes. 

Howard: My favorite bike ride. So he lives in Fountain Hills. So whenever you're flying into Phoenix, I’m towards the north, right above the Indian reservation, there's this massive fountain shooting up there and that's Fountain Hills and to leave my house to that fountain is a forty-five miles. So a lot of times on Sundays we ride up there. My other ninety-mile is the NASCAR race field downton Avondale and you leave on the south here and go to Avondale and then my short rides are around south mountain is forty-five miles to Maricopa and back but I quit doing that ride every—so I did that for about three years. Like every Sunday, we’d do those rides, but every year one of my biking buddies was ran over and killed on the bike and the last one was a guy. He retired, he went to route 65. I mean, that one was on Pecos right here in Ahwatukee and it was 9 o’clock in the morning and a guy was coming back from the Indian reservation casino. The casino nine in the morning completely shitfaced ran over him and when the cops got there, he was playing air guitar on the side of the road. Could you imagine being so drunk? And the guy was still squirming under his car while he's playing air guitar and it's like, oh.

But anyway, the last time we were going to that Fountain Hills ride in a one-mile area, me and Wendy were almost knocked out for a bike twice and then I realized it's so weird because if I said I'm going to get rid of my car and drive a motorcycle, all my smart dentist friends say, “Dude, that's dumb” because it's so dangerous. But if I said, “I'm going to ride a bicycle,” they forget about that and say, “Oh, well that's good exercise,” but you know what? When I moved here thirty years ago, you could ride your bikes on the streets, but thirty years later. I mean, losing one person that I have biked with a year for three years, I sat there and said, “I can't do that anymore.”

Dale: It's actually on the website, there's a table that shows equivalent risks of getting cancer from a formal series of X-rays. 

Howard: Which website is that on? 

Dale: That's on the Learn Digital site and it says, I think the lead-in his patient's worried about X-rays? It’s one in a million and you click on it and there's a table that comes up. 

Howard: Can you find it on your website? 

Dale: Yeah, sure and the interesting part about that is—oh, is this Doctor Cone Beam? 

Howard: No, that’s Learn Digital. 

Dale: Patient's worried about dental X-rays? It's one in a million. So there's the chart, you can look on the chart.

Howard: Can I push this out on social media? 

Dale: You can and you can look up the bicycle ride on there because it's going to freak you out. 

Howard: Well, I just quit doing it. 

Dale: Yeah but here's the deal, it's not as dangerous as you think, but these equivalent risks are from insurance, morbidity and mortality tables. So a (01:31:11 unclear) series of film-based X-rays, your risk of getting cancer is one in a million and everybody go freaks out, gets all “Well, it's ten miles on a bike.” Every ten miles you ride your risk of dying is the same as a (01:31:23 unclear) series of X-rays. Six minutes in a canoe, forty miles in a car, half a bottle of wine and one point four cigarettes so your risks. That's a great tip to hand to the patients.

Howard: What is it Ryan, [00:01:31] only drink whiskey?

Dale: Well, that's cardio protective along with ....

Howard: Again, what an honor to have you come down. Dale, thank you so much for all that you did for dentistry, for Dentaltown and for oral radiology. 

Dale: Alright, appreciate it. Thank you.

Howard: Alright buddy, thank you.

Dale: I missed this video earlier, but a friend came to visit. I don't know if you can see him. He's a black and white snake. I think a king, a smaller king snake. I shouldn't probably be getting too much closer, but you can see him kind of wrapping around the tree. Moving slowly probably looking for some breakfast, it’s still early here. There he goes, creeping away. He's about four foot, I guess black and white markings. Now, my neighbors coming up to leave home and you can see it sneaking (01:33:00 unclear) probably going to try and cross the road soon. Hello there, young man.

So Howard, this is for you, you had a scorpion on your wall. I didn't want to one-up you but this is what was crawling through my yard today when I got home from Ahwatukee to Fountain Hills. He's a good guy. He’s going to keep the little rats and the rattlers away from my house. Adios muchacho. 

Interviewer: More and more dental practices these days are using cone beam scanning technology as a diagnostic tool. My guest is Dr. Dale Miles, he is an oral maxillofacial radiologist in Scottsdale, Arizona. Dr. Miles, welcome. Can you talk about what a dentist sees in a cone beam scan? 

Dale: Oh, Scott, they see the things that they are looking for when they actually acquire the scan. They might be taking it for looking at an implant site pre-surgically. They might be taking it for something they've seen in a panoramic image, an extra tooth somewhere, an impacted tooth, but in actual fact, there's a lot more data in the scans so that they're seeing areas in the airway, in the sinuses, in the cranial vault that they may not recognize or remember from their training. So they're seeing a lot more in these scans than just what they're looking for. 

Scott: Now, how does the dentist record or document these findings? 

Dale: Well, typically in a dental office when they're looking at their images, no matter if they're intraoral, bitewings, panoramics or now, cone beam. They really will systematically look at the image, look for changes, maybe one side to the other, look for dental diseases that are typical like dental cavities or periodontal disease, gum and bone loss. 

But now when they have these cone beam sets, data sets, there's three hundred to five hundred slices in three anatomic plain subsection side to side, which we call sagittal. Front to back, which we call coronal and then axial top of the head to the bottom of the feet, which is where CAT scan came from or computed axial tomography and in those data sense is where they're going to see a lot of information that they may not be used to seeing. For example, we see carotid plaques in the neck, in the airway and unless you're used to seeing them, you won't recognize them. When they see something that they recognize of course, they'll chart it. When they see something they do not, they'll have to make a notation in the chart, some type of narrative or dictation or just a written note. So they are obligated to look at all the data in the scan and obligated to record what they see. 

Scott: Dale, are there any products that help the dentist in documenting these findings? 

Dale: Well, it's funny you should ask because a colleague of mine and myself have actually put together a cone beam reporting software. We call it Easy Riter, not Rider like the movie, but Easy Riter and it allows the dentist to look at anatomic areas. For instance, the paranasal sinuses, the nasal cavity, the airway, the temporomandibular joint, bone changes maybe in the vertebral column and by looking at statements and populating the report by checking boxes that correspond to what they see in the scan, they actually can produce, very quickly and efficiently, a formal report to put in their record to mail to a colleague as a referral document or just to store the information so that they know they've looked at the data volume and seeing everything in it. 

Scott: And Dale, going back to what you said earlier, it seems like a cone beam scanning is a useful diagnostic tool outside dentistry?

Dale: Absolutely. In fact, we not only see those plaques in the patient's neck and the carotid arteries in the neck because they capture the area of the middle of the head up by the sort of internal tint, the condyles or these joints on the side of their head. They actually will see the same calcifications in what we call the parasellar region or near the sella turcica, which is a landmark for orthodontists when they do their cephalometric tracings but general dentists are not used to looking at that area. So there's a correlation often with the patient's systemic calvin, it's up to the doc, the dentist, to find those changes and make sure that they make the proper referral and actually in our software, there's a recommendation section. There's only about half a dozen recommendations. For example, if someone sees changes in the maxillary sinuses or spheroid sinuses, they can click on a statement that says the patient should be referred to their primary care provider or otolaryngologist for clinical and endoscopic evaluation of the paranasal sinuses. 

So we think we've covered the bases. We make it simple. It's actually an educational tool as well. The more times they look at the cone beam volumes and use the software, the more familiar and comfortable they get with the changes that they will see there that are outside of their normal dental practice. 

Scott: Alright, Dale, thank you again. 

Dale: Hey, thank you Scott. 

Scott: My guest has been Dr. Dale Miles. He is an oral maxillofacial radiologist here in Scottsdale, Arizona. Thanks for watching.