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Is CBCT now standard for general dentists? When should you refer out to a radiologist? Are we giving patients brain tumors? Listen in.
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AUDIO - Anthony Mecham - HSP #123
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VIDEO - Anthony Mecham - HSP #123
Find out why is oral radiology changing and where it's headed.
Dr. Mecham has worn many caps and lived in various locations during the course of his career. After receiving an undergraduate degree in Chemical Engineering, he worked as a process engineer at Intel Corporation in Portland, Oregon before attending dental school at Boston University from 2005 to 2009. He completed a general dentistry residency and worked as a general dentist in the Air Force in Alaska as part of the Health Professions Scholarship Program. He will be completing an oral radiology residency at the University of Washington the end of June. He enjoys spending time with his wife and four children.
Howard: It is a huge honor today to be interviewing a fellow Irishman, Anthony Mecham and he tells me I'm Irish Catholic and he tells me that Mecham was an Irish [inaudible 00:00:19], so what did you say? How do you say that?
Anthony: Well, because I didn't have a name for whatever reason because I always ... Well, this is Me Cham so that's where the name Mecham comes from supposedly. I don't know if you can confirm that or not.
Howard: You're a new age oral radiologist and that's ... The American Dental Association has nine recognized specialties and seven of them are clinical and then two are non-clinical, public health and oral radiology and you’re the…
Anthony: [crosstalk 00:00:47] I might add one, pathology in there with non-clinical. I don’t know if you consider that non-clinical, oral pathology.
Howard: Okay. I’ll give you that. I’ll just go by their own press releases where they say seven are clinical, two are non-clinical but I’ll give you, pathology is non-clinical but getting the biopsies is a little clinical. This is all new age and in my walnut brain being 52 years old and graduating in `87 that this new specialty arose probably from the machine of X-rays going from 2D to 3D and…
Anthony: [crosstalk 00:01:25] Right now it’s a huge practice.
Howard: ..Basically a bunch of dentists all sitting around and saying, “How do you read this thing?” Actually I don’t like the term CBCT because I think it’s confusing. I think all Americans understand there’s 2D movies, there’s 3D movies. This is just like a 3D radiograph and I have the one from Carestream and I look at those pictures and it looks like I’m looking at something from the space shuttle, the Hubble Telescope in the deep space and they’re just hard to read, aren’t they?
Anthony: Well, I appreciate they actually admit that. A lot of people I talk to they’ve read radiographs forever and so they think, “Well, it’s just another modality. We can interpret that. We can read that.” First time you look at it, it’s really confusing and it takes some time to get used to it. It takes a lot of education, a lot of additional training I think than what you see in dental school to really be able to read those.
Howard: I’m in a group practice so there’s always been about three of us for the last 20 years and there’s usually a dentist popping his head in there every day from somewhere whatever and I can’t tell you how many times three to five dentists have been looking at a CBCT and we’re all pointing and saying, “What’s that?” No one knows and sometimes it’s just crazy great. Tell me you got out of dental school in 2009, right?
Howard: Then you went straight into residency, into oral path or?
Anthony: No actually I did just a AGD residency with the Air Force. I signed up with the Air Force, did the three year HBSV Scholarship Program and I was up in Alaska for a few years with the Air Force.
Howard: Oh my God, that’s the most beautiful state in the country.
Anthony: Yeah. You’ve been there?
Howard: Oh my gosh, I have. My dad and my brother we went up there and we flew into Anchorage, drove down to Homer, went alder fishing and rented a helicopter on the Kenai and went salmon fishing up where there weren’t even roads or cars and then we drove all the way to Prudhoe Bay.
Anthony: I agree, it’s amazing up there. We were kind of sad to leave.
Howard: The Air Force taught you how to read these things?
Anthony: No actually, then when I was done with the Air Force I did the Oral Radiology Program. I didn’t have that much experience in the Air Force. We had to cone beam CT and I’d look at it with our oral surgeon once in a while but no far from being prolific at interpreting it.
Howard: What made you go into this?
Anthony: A lot of different factors. I always thought I wanted to do some sort of specialization. I’ve considered each and every one at some point. Dentistry is kind of hard on me on my back. I’ll just go ahead and say I have ankylosing spondylitis. I have back problems with doing dentistry and I was looking at different things that are non-clinical and I didn’t even realize it at the time that it was a recognized specialty so I started looking into radiology. I went to the 2011 AAOMR meeting, that was in Chicago and I just really loved it. I really thought there was a huge future in radiology and still I see a huge need for it out there.
Howard: How long have you been a specialist in this?
Anthony: Actually my last official day of residency was yesterday.
Anthony: Today is my first day of freedom, first day of actually starting … I’m trying to start the private practice of radiology.
Howard: Let’s just start again, the big million dollar question is … Not a million dollar question, the $150,000 question. Do you think a general dentist should buy one of these for their office?
Anthony: It’s a good question. I did a little research for this. You’ll probably agree this is really hi-tech research. I use Dental Town. I asked of solo dental practitioners who own their own cone beam CT how many of them thought it was profitable. Most of them said they broke about even. Only 14 responses said even but 12 of them said no and only seven said yes it was profitable. The first solo practitioner, likely it’s not going to be profitable.
Of course you have other things to consider if you’re going to be doing a lot of implants or a lot of the tricky endo where you might need a cone beam CT with a really high resolution to try to see if there’s possibility of fracture or perforation. If you’re doing a lot of those things where you’re going to be using it, obviously it makes sense to get it and there are other considerations of it other than just the bottom-line of, “Am I going to take enough cone beams to make it profitable?”
Obviously it’s kind of a marketing tool for your practice. There’s a lot of benefits about it but I don’t think every practitioner has to own one. Obviously it’s a huge investment, coming out of dental school already with a ton of debt, maybe $150,000 more, is the last thing you want think of. I’m going to quote Gordon Christensen here. He said he thinks everyone should have access to cone beam CT and I think that makes a lot of sense.
There’s a lot of things that makes sense with kind of the imaging center, having someone that just does that all day, that’s able to really specialize in getting the best images possible. Then also they’ll be outdated every few years, maybe every five years they come out with a new and updated cone beam CT and so just trying to be able to keep up and have the new and the best out there. I think there’s a lot of advantages to doing imaging centers but unfortunately with some of the people I’ve talked that have these imaging centers they’re not doing that well because everyone wants to have their own and I understand that mentality too.
I think if I were a general dentist I like staying on top of technology. I like having all the new bells and whistles and so I understand both points of view, but again I think as long as you have access to cone beam CT, like you said before if you don’t have one there’s tons of specialists that have them and likely they’ll be friendly to your request to just refer a patient for cone beam CT.
Howard: Are there any national radiographic centers for oral radiology or coast to coast and all 50 states or is it mostly just little city by city companies?
Anthony: As far as I know it’s kind of city by city, specific ones in each state. I don’t know any that have a national wide brand that have their own … Across all the state borders.
Howard: Do you know the names of any regional players? We’ll probably have about 5,000 that is listed in this from all over. Is there any other names off the top of your head that some of these guys might look into?
Anthony: Well, I’m in Utah. That’s where I’m planning on ending up and where I am right now and I’ve talked to the guys in Utah. There’s a oral and maxillofacial imaging center in Salt Lake and so that’s … Kind of the center of the population in Utah is in and around Salt Lake and that’s in Murray, Utah. Then also around my hometown of South Jordan is Ultradent and they have an imaging center but both of them they haven’t been that successful at getting a lot of referrals. I guess people just want to have their own kind of ways training.
Howard: Have you met Dan Fisher?
Anthony: No I didn’t meet Dan Fisher. I met a couple of other guys in there.
Howard: Oh my God. Just go in there and tell him that Howard Farran sent you guys. He is the neatest guys in the world.
Anthony: That’s nice.
Howard: Nobody works harder, nobody is more nicer. He has so much integrity. I mean he’s just one of my top five role models in life and just an amazing man.
Anthony: Well, the people I met there they were really impressive and I actually applied for a job there.
Howard: You’re still looking for a job there?
Anthony: No I think I’m mainly going to try to make this radiology thing work out, private practice radiology. That’s the …
Howard: [crosstalk 00:08:56] If someone takes a CBCT, do you think a board certified oral maxillofacial radiologist should read them all?
Anthony: That’s a good question, kind of the elephant in the room right now especially with the latter radiologists. I don’t want to make people mad with my opinion but I do have my opinion. There’s a lot of doom and gloom radiologists out there to say, “You’re an idiot if you don’t refer every single scan that comes out.” I kind of agree with that sentiment but I don’t want to be one of those guys. I don’t want to be, “You’re an idiot for not referring … You have to refer everything to me.” The main reason is if we made a law tomorrow that said, “You have to refer every cone beam CT to an oral radiologist,” there’s just are enough that’s out there.
With dentistry a lot of times I think you have to think of what’s the best possible outcome for the patient? Maybe it’s not always about what’s ideal. If we talk about what’s ideal, I would say have at least two radiologists review every cone beam CT because even the top radiologists out there … I want to give a shout out to Lars Hollender. He’s the Professor Emeritus at University of Washington who we all love and respect.
I know Dr. Gonzalez when she was on here she mentioned him as kind of being a mentor and influencing her decision to go into radiology but even he’ll admit, he doesn’t think he sees everything and he stays awake at night worried about what he doesn’t see. I think if we went by the ideal in this case for radiology we’d have at least a couple of people who know what they’re doing, look at it and okay, that everything’s okay but then you do have to make that decision.
You can’t always do the ideal. Dentistry if we always we did the ideal everybody would have gold fillings or the gold crowns but we’ve gone far away from that. I think we’re left with what’s the best thing we can do with the resources we have and right now there’s only say about 200 oral radiologists out there and there’s a lot more…
Howard: [crosstalk 00:10:59] Only 200?
Anthony: It’s a tough number to keep track off but I think it’s around 200, maybe even less than that that are board certified. I’m not board certified yet. It’ll take another year before I take both of the exams, but oral radiologists who are out there actually practicing, the number’s even less than that. A lot of oral radiologists still just work for schools and are happy to be involved in academia and doing research. What I was starting to say is if we made a law tomorrow that every cone beam needs to be read by oral radiologists we just couldn’t keep up with it. I think we need to do the best thing that we can and that’s, improve the education of the general practitioner.
I think everyone would admit the education we get in cone beam CT in dental school is fairly minimal to none. Like you said we start looking at those things, it looks like you’re looking out and out of space something you’ve never seen before. It takes practice and it takes training. I think there’s a huge need out there and I want to start making some online courses. We talked before about maybe doing some links to that on Dental Town, but I definitely want to start developing some online courses, start developing training for general dentists to be able to read, to interpret cone beam CTs.
Howard: Let’s start with that. Let’s start with a dentists … I always try to guess questions, what are the most relevant questions for my listeners and we kind of hear that, like if you’re an endodontist that you might want a specific brand of machine because it’s better at a just like a tooth level, whereas if you were an orthodontist you would want a different type of machine. Is there a machine now that can do any dental procedure from A to Z or would you be giving different recommendations of machines to buy to an endodontist versus an orthodontist versus someone that’s just doing implants and surgical guides?
Anthony: There’ll probably be different recommendations for each. Endodontists of course there are…
Howard: [crosstalk 00:12:55] Can you go through those for the types of different dentistry and actual name brands?
Anthony: I don’t know the name brands and specifically which ones would have … I know Kodak with [inaudible 00:13:07], they do a lot with endo so they probably would have a lot more the high resolution stuff but if specifically what you’re looking about without really going into name brands, endodontists they’re going to be concerned with the high resolution stuff. All of them advertise now they have super high resolutions, super small voxel size down to the low 0.1 millimeter voxel size.
Another thing you need to consider when looking at resolution is not just voxel size but focal spot. If you have this 0.1 millimeter voxel size or your focal spot is 0.5 millimeters, that’s like having a super ultra-high def television but you’re only getting standard definition signal, and so there’s a lot of different things to consider. As far as I know they may be coming out with newer and newer things every day. Of course they are but as far as I know Prexion has probably the smallest focal spot of 0.15 millimeter.
Anthony: Prexion. It’s not a very common one.
Howard: Where is that? What country is that made in?
Anthony: I’m not even sure where they make those, just something I’ve looked into, so much I look into more … Maybe some of the newer models of some of the more common brands have smaller focal spots and that might make a big difference. Again, this is all kind of theoretical that I’m going by. I’d like to see some of these images, not just from what the vendor show you. Of course they all look great but some actual in use machines that are installed in people’s office and see how they really look.
I guess maybe it’s a call to action, if anyone wants to send me images if they have a Prexion from any different brand I’d love to take a look and really see and compare the two because it’s hard to compare just talking to the different because they’ll say anything to sell to you and their images always look great and top quality. It’s just certain things you need to consider. When you’re looking at endo it’s the high resolution. When you’re looking at TMJ or ortho you want a larger field to view and so you have to get one of those that does the expanded field to view.
Howard: You should start another thread on Dental Town asking that…
Anthony: Yeah for sure.
Howard: …Setting of the picture. Did you see, it’s all over social media, consumer reports put out a deal on is it dentists taking too many X-rays or radiation. Did you see any consumer reports articles on…
Anthony: Is that referring to that article a few years ago about bitewings causing meningiomas?
Howard: I think there was a 2012 one.
Anthony: The 2012?
Howard: Then they just counted another one in 2015. I just saw it flying all around the Internet.
Anthony: I didn’t see the newest one but well those are kind of along the same vein and if it’s similar to that 2012 one which was kind of hogged or kind of just a scare tactic trying to scare people and they got what they wanted. They got a lot of attention with their headline, “Bitewing radiographs, dental radiographs cause meningiomas, cause brain tumors.” Which if you look at the way they did the study it was about the worst you could do.
It was all based on just anecdotal evidence looking at memories of people and X-rays that were taken up to 70/75 years ago and so just a really poor study. Another questionable thing is some of those, the bitewing showed more of a correlation than a full mouth series of X-rays and how you can explain that, I don’t know. There’s really not, I don’t think a lot of good information that should scare us into saying bitewings or dental radiographs are causing…
Howard: [crosstalk 00:16:42] Well, on that note let’s just go into … Now that you’re a new graduate you should have a lot of this data fresh in your head. What is the criteria of when to take X-rays on a new patient? Some practices, just every new patient they taken an FMX and a pano, some take a pano and just bitewings. Some take it every five years I think because interns phase every five years and they assume, well if the interns phase every five years that they’ll get [inaudible 00:17:09].
Anthony: What every five years?
Howard: I mean or an FMX or whatever but can you walk through when you would take X-rays.
Anthony: I think what’s the most recent from the ADA like 2012 and then those guidelines explicitly say it. It kind of gives you a broad range for each category and again Dr. Gonzalez referred to that paper. We could put another link into that ADA recommendation again but when you have a new patient … I don’t think FMX for a new patient is always the ideal thing but again with these guidelines it leaves it all up to interpretation it seems like that you leave it up to the dentist’s best judgment, and so there is a lot of variation in there.
Howard: Well, go through, okay I’m 52, I just come into your office today and I’m a new patient and you just met me and what would you…
Anthony: [crosstalk 00:18:06] Did you bring any X-rays with you?
Howard: No X-rays.
Anthony: If you’re 52 and I see maybe you’ve got a lot of dental work I don’t have a problem with doing a full mouth X-ray, a full mouth series of X-rays, doing a pano. If it’s someone younger with obviously not a lot of fillings maybe you do a pano and bitewings and then that’s probably sufficient.
Howard: Do these 3D CBCTs, do you think that’s too much over radiation to get a pano and bitewings because some of these CBCTs, don’t they extract a two dimensional pano and four bitewings out of it?
Anthony: Yeah that was at the recent Utah Dental Convention, looking at the different CBCT machines and now Planmeca have this ultra-low dose radiation cone beam CT as low as 15 microsieverts which is along the lines of a pano and so I said to them, “Are we going to stop doing panos?” It seems like it may be heading that direction. If a pano is the same dose, you get just the same or you get better information from a cone beam CT and you can recreate the pano.
Some people have problems with the recreated pano but I think you can get over that because the real complaints about the recreated pano is you don’t see those shadows in things that you’re used to seeing which aren’t really diagnostic or helpful anyway.
Howard: Does it also recreate the bitewings?
Anthony: Of a cone beam CT or the pano?
Howard: Yeah, the Planmeca one. You said the Planmeca one will recreate a pano. Does it also recreate bitewings?
Anthony: They advertise it as recreating bitewings. I kind of think anyone that’s really a proponent of that is really trying to sell those. If you look at them side to side, the pano bitewings compared to regular bitewings, I think hands down the intraoral always look better and it just seems like you get a lot more information. They said they were going to do some research pretty soon in the future and to stay tuned, so we’ll watch for that research to come out to show maybe it is diagnostic.
Maybe you can get a diagnostic bitewing from a pano even if it doesn’t look quite as pretty but right now it’s say we’ll still have an intraoral. Those are still kind of the way to go to look at bitewings, to look at intraoral carries and things like that.
Howard: Well, I’ll tell you what, that is one hell of a company. Planmeca is in Helsinki, Finland. When I was in Helsinki I went down to the company. I mean wow those guys are intense and I think one of the reasons they’re so intense is because since it’s so damn freezing for half the year I think everybody likes just to stay in and work their ass off. The work ethic out there in Scandinavia is crazy.
I do think it’s weather related. I seriously do because a lot of dentists told me when I was in Sweden and Denmark and Norway and a lot of those countries they say, “Well, you know there’s not much to do in the winter anyway so I usually get to work at 6:00 in the morning and usually don’t get home till 7:00 at night and then I take all of the August off.”
Anthony: That’s kind of how it was in Alaska. Everybody will work long hours in the winter. It’s all I have to do anyway then take great big fishing trips the whole night.
Howard: What’s so hard about visiting those countries is when tourists go there like June, July, August when it’s most beautiful, all the locals are like, “Hell no I’m not working and I’m not waking. I’m not cooking. I’m going down out there.” The parks are just filled with all these people laying out and playing and having fun. The restaurants will be like one poor waitress and she had like 20 tables to wait on, so it’s kind of a tough job. What do you think about if a person wants to do implants, what do you think of the surgical guides?
From the point of view, do you the surgical guides are as accurate as these people think they are. A lot of people think well this CBCT it’s down to the microns so if I make a surgical guide and had a stop point here, absolutely I’m never going to hit the metal frame. I’m never going to hit anything because this thing is just too exact.” Is it that exact or can you really still…
Anthony: I think as far as having the stop point, that’s something that can be controlled pretty well. Of course there’s a little room inside the sleeve and so it’s accurate as you can get. You can be a little off with the sleeve but as far as the measurements those have been shown to be accurate. They are pretty reliable and if I were asked if I would recommend them for doing implants, for each implant case, it’s probably good to get started out and I know Gordon Christensen recommends not doing them for healthy patients, single tooth implants and that’s fine.
Of course everything takes practice. Maybe the first few you do you want to have a guide just to make sure you’re doing things right and make sure everything is lined up, but yeah I do think they’re accurate. I think it’s been shown those cone beams are pretty predictable.
Howard: It’s a tough controversy because since 94/95% of all crowns and/or implants are done one tooth at a time. I mean the whole mouth rehab market is just a fraction of the one tooth dentistry market and a lot of the old timers and a lot of the oral surgeons think, “Well, you know you need to learn how to be a surgeon. You need to learn how to lay a flap and you’ve got a tooth in the front and back and you lay the flap and you see the bone and you should be able to do this.”
A lot of those guys just say, “Just lay a flap and do it.” Then of course everybody wants to do everything faster, easier, lower cost, better and it just seems you all get stumped in a [inaudible 00:23:36] blah, blah, blah but yeah it’s a big controversy. I wrote my next column on it that much just because I knew it would be the ball where everybody is talking about. When is cone beam the standard of care? I know that’s a loose definition. I know the lawyers can’t agree on what that means.
Anthony: I don’t think it’ll ever be exquisite but it is necessarily the standard of care for such and such procedure. We have a lot of different people saying it is quickly becoming the standard of care for things like implants maybe for wisdom teeth extraction. When you see an overlap on the pano of the wisdom tooth and the IAC but I don’t know if it’ll ever explicitly be put into lot as a standard of care, but does that mean it’s not really going to be standard of care? I’d hate to be a dentist where I did an implant.
Let’s say I went into the mandibular fossa, did some damage and then I’m in a courtroom and they show these images that someone took of this implant that’s sitting there outside the bone because I didn’t know there was this big deep fossa 00:24:38. I’d hate to be in that situation, and so whether it’s standard of care or not, I think these are just things to consider.
Howard: The only thing I tell a lot of dentists, they can see a gazillion patients a year for 40 years, they get sued one time and they just take it so personally. It is so bad and I always tell dentists that the date I’m looking at is if you practice a full career you’re going to get sued at least once and the only frustration about that is the malpractice, dental insurance company because they’re the ones that are going to write the bill for that.
Just like I don’t worry about wrecking my car because State Farm should have to worry about that not me, but do you have any market penetration data or gut instincts? Like there’s 5,000 oral surgeons, how many of them do you think are using cone beam for wisdom teeth and implants? Do you have any data? Do you have any inputs?
Anthony: I don’t have any real data but it seems like more and more, it’s still probably if I was just going by gut, less than half, 25/30% but it’s constantly growing. I think in five, 10 years maybe most of them will be using cone beam CTs.
Howard: You’re right, it is less than half and I can rattle off 10 names of oral surgeons that have placed 30,000 implants and say they’re just completely like, “I know you’re surgeon. Why would you need a surgery? I just have a single tooth.” Gordon…
Anthony: [crosstalk 00:26:01] They don’t use cone beam meter or do they use cone beam to kind of map it out to see what they’re getting into?
Howard: I think a lot of them have cone beam just because if you sunk 30,000 implants you’ve got more money than Moses. You can buy anything you want so I think they have them but I just think they’re just old school boys that just sit there and think, “You know what, if you want to be a doctor, you’re going to have to learn to lay a flap and the faster you get to learning how to lay a flap the faster you’re going to be a surgeon.” They don’t like any training well things. They think you need to just lay it out.
Again we’re talking a single tooth where you’ve got a tooth in front and behind. We’re not talking about some of these dentulous person where you’re trying to put four implants in there and you need to know where the metal frames are, you need to know etcetera. When should a dentist refer to a radiologist?
Anthony: Like I was saying I think there should be a lot more training and I think once you’re comfortable reading cone beam CTs, looking at what the normal anatomy is and of course I think anyone would admit that every slice of the cone beam CT needs to be examined, needs to be looked at and you need to be able to recognize normal from abnormal.
That means knowing what the normal anatomy is, what it looks like, what you should expect, what normal variations are and that requires time. It requires looking at a lot of different cone beam CTs. I think every dentist could get to that point where they’re comfortable reading it and once a dentist gets to that point, maybe just refer when you have a question.
Obviously questions will come up even with at UDAB with our team of radiologists there’d be things where we discuss for hours and we didn’t know what the heck is going on. They’ll always be questions that arise and in that case I think someone should refer to a radiologist have a look at.
Howard: What do you think it’s going to end up being? Does the 80/20 rule come into play here and do you think 80% of them are going to be standard and fine and 20% need to be read or do you think it’ll be reversed? Do you think 80% will need to be read and 20% will be just normal?
Anthony: It kind of depends on who it is referring. Are you talking about after someone has a question and then refers out to a radiologists with a question?
Howard: No, just the average general dentist.
Anthony: In general?
Howard: If all the general dentist bought a CBCT and their protocol for taking them, what percent do you think overall do you think will probably need to be read because..
Anthony: I think that really depends on the comfort level of the dentist looking at it. Again, if he got that additional training or tons of experience looking at them, maybe he only needs five percent, maybe he’ll have questions. Conversely if someone is fresh out of dental school have never looked at a cone beam CT, right up front they may need someone to go over those with them and may need to refer every one of those to someone to go through and talk about what the anatomy is and what they’re looking at.
Howard: If they get to work in 30 minutes most of the people that listen to my podcast have an hour to commute, how would they actually contact Anthony Mecham? Mecham or Meacham?
Anthony: I was first Meacham but it’s changed and now it’s Mecham.
Howard: Meacham is Mecham?
Howard: They go to oralradiologist.com?
Anthony: Yeah, oralradiologist.floral.com.
Howard: Oralradiologistfloral.com or firstname.lastname@example.org, but how do they send you … Go through the specifics. How do they technically send you a CBCT because that’s a big damn file?
Anthony: It is kind of a big thing to do and I’ve tried to carefully make an instruction form on my website. If you go into … You have to look for where the instructions are but there’s a form that walks you through it. Most of them are saved in dicom format and what that means is hundreds of different files inside a folder and what they’re going to have to do is zip that folder and they’re going to have instructions, in an instruction form and how to zip it and how to give it to me.
Basically if you go outside that folder and then it depends on what version of Windows you have, you either have to right click it and then click zip or compress or in newer versions of Window, there’s a share button up top. Once you highlight that folder you click a share button up top in Windows and then it’ll say either compress or zip and that saves it as a separate directory.
Howard: Is compress and zip the same thing?
Anthony: That saves it as a separate file. It looks like another directory and that you can upload right to the website. If anyone has questions, again that email … You go on the website you look up my contact information, I can walk them through it.
Howard: Do you take phone calls?
Anthony: Yeah, I’ll take phone calls.
Howard: Enough to give out your phone number now or would you rather they just go to oralradiologist.com?
Anthony: I’d give it out now.
Howard: What’s your phone number?
Anthony: I might change it sometime soon because I still have the Boston area code number from when I was in dental school. I’ve never updated it because it’s my cell phone but it’s 617-347-5670.
Howard: Okay. Say it again.
Howard: You should keep the Boston number because you’re Irish and a Celtic.
Anthony: That’s true.
Howard: You know Irish catholic, I don’t know.
Anthony: I like the patriots.
Howard: You’ve got to root for the Celtics at the Boston Celtics and/or Notre dame if you’re really an Irish Catholic, right? Is it okay to refer out of state to radiologists? Is there anything with that? You’re not licensed in Arizona, you’re in Utah.
Anthony: For the most it’s okay. Some people say it’s kind of a gray area but for the most part you’re fine. If you look at the laws that are in place, a lot of it is kind of gray area and it’s not really outlined. There are a few states where they explicitly say the … I don’t think they mention radiologists specifically but if anyone does any sort of interpretation or diagnosing they have to have a license in that state and those states I wrote them down here.
It’s New York, Florida, Georgia, Alabama and Washington. Those five states are pretty exquisite that the radiologists or whoever you referred to have has to have a license in that state.
Howard: Say those states again.
Anthony: New York, Florida, Georgia, Alabama and Washington and again you need to look at the laws in your own state, I haven’t.
Howard: New York, Florida, Georgia, Alabama and Washington? I just did not know there were teeth in Georgia and Alabama. This is all news to me. I’m just getting…
Anthony: [crosstalk 00:32:35] We’re not just [inaudible 00:32:36].
Howard: I’m from Kansas but anyway they’re very, very interesting. I want to ask some standard questions that I get from patients and dentists, just the obvious [inaudible 00:32:50]. What is CBCT? Where the hell did they get that name and what does CBCT mean? Then there’s a lot of people going around saying that like the Carestream I bought.
That technic viewer like a scientist lawyer, it’s not even actually a CBCT anymore. That was an earlier technology and that they don’t do it anymore. Define what CBCT actually means? Where did the word come from? Is the current CBCT is not really even a CBCT?
Anthony: Is that a newer CBCT, your Carestream you’re talking about?
Howard: I mean whatever it was two or three years ago.
Anthony: Well, cone beam CT means a CBCTs for cone beam CT, meaning compared to medical CT which is if we go to our traditional medical CT it’s a fan shaped being. They do one row.
Howard: Is the medical CT a CAT scan, is that what you’re seeing?
Anthony: Right. It’s called the CAT scan, the medical CT. That’s what people are maybe more familiar with in general.
Howard: A medical CT is a CAT scan?
Howard: See my HMO…
Anthony: [crosstalk 00:33:55] A CAT scan is just kind of a colloquial name.
Howard: My HMO and Obamacare, when I go to the doctor my CAT scan is they just bring in a cat and it just walks around me and sniffs for about five minutes and it’s all covered. A medical CAT scan is…
Anthony: [crosstalk 00:34:11] Your traditional one is a fan shaped being where you just have one row of detectors and it goes around the patient. It’s also called helical CT because it goes around in basically the form of a helix, so many times around the patient. Of course now that’s changing as they’re getting multi sliced detectors. If you go on any hospital now they’re not going to have that single roll of detectors because that takes so long to go around the patient, a thousand times or however many hundred times.
They have either 32 or 64 row detectors. It’s getting up to the point where it’s even like 128 rows. I think even more than that. It’s getting to where their beam instead of being more a fan is almost like ours where it’s a comb and so there are people that agree with you, that’s kind of a misnomer, the cone beam CT. The cone beam CT is inherently different. We have a flat panel detector and basically it’s like taking a staff at each little increment around the patient and you only go around the patient once.
We see it go around. It goes around pretty slowly and depending on your settings and so you take several hundred steps of this patient and it takes each of those two dimensional images and from that reconstructs the CT data. Whereas the helical CT or medical CT, it takes now up to several rows at a time but it goes several times around the patient and takes like one axial slice at a time of the patient then reconstructs it from those axial slices.
Cone beam CT, I can see where the name came from and we kind of grew on accustomed to it but it’s a bit of misnomer because they are, as far as the cone beam that’s getting more similar to the medical CT now.
Howard: Why did they go with the CT? First of all, what is the difference when you go to the hospital and they do a CT versus an MRI? Why do sometimes they get CAT scan, sometimes an MRI? Is it because an old hospital uses the old CAT scan and the other one use an MRI or not?
Anthony: No most of them have both now and so CT is quicker. It’s less expensive. There’s a lot more availability. If you have someone in emergency situation it’s a lot quicker just to run them into a CT machine. It is similar to the cone beam CT where it’s ionizing radiation using X-rays and I kind of explained already how they reconstruct that with a medical CT. An MRI, that instead of using ionizing radiation is using just basically magnetic field.
You sit inside this big magnetic field and then they have different ways of changing a magnetic field, different increments throughout the length of the scan and that’s the way that they encode the signal that they get. They have this big magnetic field then they induct a signal, just another transverse magnet station or RX signal and they have different ways of coding each pixel inside the patients so that when they measure the signal coming off the patient they can tell where it came from and reconstruct that as an image
Instead of using any ionizing radiation it’s just using magnetization and you get an image from that. It’s a lot better looking at soft tissues. You can look at discs. A lot of people will get them … For dentistry we may see them looking at TMJs because you can see the discs or you can see soft tissue a lot better whereas for CT or cone beam CT you can see hard tissue and I’m not going to…
Howard: Do you see MRIs eventually? Do you see these cone beams eventually going to MRI or is it that just logistically not really possible and will probably always be a CAT scan?
Anthony: That’s something where me and Dr. Hollender disagree. He thinks that there’s no way that MRI will ever be low cost enough and small enough to be used for dental. They’ve already been doing some research with … They have to use super high magnetized MRIs to be able to but they can image hard tissue and they’ve shown … I’ve seen some research where you can actually see the hard tissue of the teeth and you can see it so much clear than you can in an X-ray.
I think there’s a lot of potential there. Whether it will come down in cost and size is another story but if you consider the biggest thing contributing for the cost and size of MRI is having to cool down for the magnets. They’re using electromagnets so they have to cool those coils down to become super conductors. They have to use liquefied helium in order to do that and that’s what makes it such a huge expensive costly device
If they were able to come forward, advance enough in materials, if they had a super conductive material that didn’t have to be cooled that much, I think you could bring down the size and the cost of an MRI. I don’t think it’s going to happen anytime in the near future. We’re a long way from that but maybe some time in my lifetime we could see a dental MRI.
Howard: Just think because miniaturization is a business model that everybody has. We’ve seen it when it first came out. It was so huge. They could only use it to pump water out of coal mines and then it got small enough there, then it could run a ship and then it got small enough to run a train. This iPhone right here is amazing for how big the first computer was and then to a couple of decades it was a personal computer and now that damn thing is in my iPhone. You know what I mean?
Anthony: Yeah. I think it’s…
Howard: [crosstalk 00:39:34] Everything always get smaller every year except for my gut.
Anthony: If you look at the advancement of technology it’s just a trend. You can never rule anything out. I don’t think you can say it’ll never happen but I think you can say it’s not going to happen very soon.
Howard: Then are you okay … We’re on the frontlines, you’ve got all these general dentists and you have all these patients walking in, are you okay with the dental staff, the assistants, hygienists and the dentists just saying, “This is our new CAT scan machine. We used to have a 2D X-ray machine and now we have like a 3D CAT scan machine.” Are you good with that or is that wrong?
Anthony: I think if you say CAT scan, I think that’s the wrong thing too because I think we definitely want to differentiate cone beam CTs. Whether you call it cone beam or whatever you call it, I think you want to make sure to differentiate it from medical CT mainly because of the dose and the risk associated with it.
Howard: You think the CAT scan has a bad brand name because they’ll be thinking, “Wow, that’s a lot of radiation?” Is that what I just heard you say?
Anthony: I don’t think it’s necessarily bad but it is on average say around 10 times the dose of a cone beam CT and I think that’s one of the huge advantages and one of the things that we should really talk about and focus about with cone beam CT, is we’re so much less dose and yet we still get this 3D image and for the dental needs, it’s really great.
Howard: Do you think we as dentistry … The funniest thing I ever saw a couple of years ago, the endodontist was trying to launch this campaign that quit calling it a root canal and call it endodontic therapy and it’s like good luck with that. You know what I mean? The whole world knows a root canal. It’s kind of like in Phoenix, we need to quit calling these monsoons now, we have to call them haboob but when you’re out with all the real people they all call it a monsoon.
I mean maybe one person per summer calls it a haboob. You know what I mean? Do you think dentists should get behind this and should we just start building a brand name CBCT or? I’m just telling patients we’ve gone from 2D and now we’ve got data 3D.
Anthony: [crosstalk 00:41:37]3D. You can call it a CT.
Howard: I totally agree actually.
Anthony: I would rather call it like a dental CT. I think that’s kind of…
Howard: [crosstalk 00:41:41] A dental C…
Anthony: A dental CT might be a good term.
Howard: A dental CT.
Anthony: If I had to choose my terminology for it maybe I’ll just say, “We’re doing a 3D dental CT.” You can say it how it’s similar to a medical CT.
Howard: What’s a CT stand for?
Anthony: Computer Tomography.
Howard: You think that’s a brand that we can eventually have all of America saying, a dental CT?
Anthony: It might be hard to overcome, so many people already call it cone beam CT and it’s such a familiar phrase when talking about these. I don’t know if that’s ever going to go away.
Howard: Yeah. Tell us this then, what is your biggest takeaway or give us some low hanging fruit of what you did know on reading a CBCT versus what you know now after going through … Well, how long was the residency?
Anthony: Two years from…
Howard: Two years of just focusing on one name, what sort of the low hanging fruitnology you can transfer to the general dentist listening in their car right now?
Anthony: The biggest thing that I think that I had to learn over and over because as far as I hit myself in the head, is you have to have a systematic way of going through things. First of all you start looking through each slice, each different orientation one slice at a time but then you also need to look at, okay make a checklist, did I look at the TMJs? Did I look at the sinonasal area? Anything that’s in the field of view of the scan?
Did I look at all of the dentition? I kind of got out of the habit of looking at the dentition as I got more and more into looking at panels and looking at everything else around but I didn’t see when I was a dentist. I got so into looking at that that I forget to look at the dentition and not look at obvious carries, and so definitely you need a checklist. You need to make sure you’re looking at every square inch of a scan.
Howard: Do you have a checklist?
Anthony: I do.
Howard: Is it on your website?
Anthony: I don’t have it up there yet. I’ll put one together.
Howard: Could you start a thread with your checklist?
Howard: On Dental Town I’ll tell you for you for marketing when you put this on Dental Town that’s content but in your signature area you can have your name, Tony Mecham or your oralradiologist.com and all that stuff. Every time you’re mesmerizing them with your knowledge, they’ll be seeing your signature area, your name and contact and your avatar should be your face and dentistry.
All those things will be fantastic marketing for you. I mean one of my ironman buddies that I run by, can swim with is a pilot and he’s always telling me that most of the plane crashes are solo practicing pilots and one of the biggest errors they make is they don’t have a pre-flight checklist. He’s a professional pilot and even being a professional for decades and decades they still absolutely go through their checklist every single time.
Anthony: If you don’t do a checklist you will miss things no matter how many times you’ve done something. That’s kind of when you get in the danger is when you’ve done something so much, you feel like, “Okay, now I’m comfortable with it. I can just fly through it and I’ll see everything,” but yeah you miss things if you don’t have that checklist.
Howard: Right. You recommended looking at everything in the same order so one of your big takeaways is … We do that with patients. One of my pet peeves that I can’t stand is when a little kids goes into the dentist they get a cleaning and the high dentist flosses their teeth. You don’t see that in any other sport. You don’t see when you go to wrestling or karate or gymnastics or T-ball.
You don’t see the coach out there do it while the kid’s down, the kids are doing it while the coach is coaching. It’s funny because I’ll go in there and I’ll hand the kid a floss and you know it’s the only time he’s flossed in the last six months and they usually go right to the middle teeth and I’ll sit there and say, “No, no, no we do it the same way every time.
We start on the upper right and go round. We start here. We go round, we drop down, we come back.” Same thing with brushing you just see areas where they’re going to be like two plates of tartar on the buckles of their … Between their maxillary molars on the buckle and you can tell they’ve never brushed ever because they brush every time the same time, so yeah I’ve got…
Anthony: I’ve got four kids and I still hold them down and brush every one of their teeth. The older ones, the nine and six year old I let them do it on their own once in a while but I want to make sure it’s clean and I give them a good cleaning every once in a while.
Howard: I’ve got four kids too. Mine are 20, 22, 24, 26 all boys.
Anthony: Nice. I’ve got two and two.
Howard: Two and two? You mean two sets of twins?
Anthony: Two boys and girls.
Howard: Two boys, two girls?
Howard: What are their age?
Anthony: Oldest is a girl nine years old and a six year old boy, five year old boy and then a two year old girl and we have one on the way, just found out yesterday, another boy.
Howard: Wow, congratulations. I kept trying to have a girl and I never did so that means I’ll die alone in a nursing home and no one will visit me. You just need one girl and you would add a visitor in the nursing home. What other low hanging fruit takeaways did you learn from saying this for a couple of years?
Anthony: The biggest thing I learned was just the sheer number of pathology cases, I did research on recording on cone beam CTs and we had like 150 cases, almost all of them we kept a few normal cases in there just to keep us on this but almost all of them have pathology in it and I think one of the really biggest strengths of the program was sitting down again with Lars Hollender, with the other great radiologists there and just going through case by case and me coming up with a differential diagnosis.
Something that’s hard to convey is just the only thing I can teach in a minute. It’s more of something that you need that experience of going through case by case and seeing that much but if I can take a minute I want to go back to something I talked about. I think I may have opened a Pandora’s Box. I may have given the impression that I feel like I’m not afraid at all about radiation and the dose we’re giving our patients which is not the case and I subscribe to the ALORA principle and…
Howard: To what principle?
Anthony: ALORA, As Low As Reasonably Achievable as far as radiation goes.
Howard: As low?
Anthony: As Low as Reasonably Achievable.
Howard: I haven’t heard of that.
Anthony: You’ve never heard of that? I guess that’s more than common in recent years but pretty much every dental school is teaching that principle. They may change it soon to ALODA, I’ve heard of that. As Low as Diagnostically Achievable, which might make a little sense.
Howard: At our school they taught YOLO, you only live once and then they just blast you and that was it.
Anthony: Yeah it’s changed a bit but now there is research, in fact recent research that shows that the linear no threshold, those theory is reasonable. Just in 2013 in Australia they did a study of 11 patients, many of them had CTs either as children or young adults and they do show a correlation with increased risk of cancer and so that’s a good data that shows low dose radiation is a risk.
There’s other theories out there, the [inaudible 00:48:47] theory but I do subscribe by the linear no threshold. I think that’s good and conservative and we should try to stay away from overdosing our patients. I think it’s a great thing what the cone beam companies are doing now. A lot of them are focusing on the low dose. We see some of those coming out with 15 or less microsieverts dose and it’s pretty impressive.
Howard: It is frustrating when you have patients come in, they don’t want a shot and they are wearing 20 body piercings and in Arizona they come in they don’t want radiation X-rays and they’re basically in shorts and a tank top and their like nuclear red brown skin and the only real good debate I got in this month with X-rays they had a pack of Marlboro red cigarettes in their pocket and I’m like, “Really you’re arguing with me about radiation and you smoke a pack of Marlboros a day?” I mean at that point…
Anthony: [crosstalk 00:49:34] Yeah, it keeps things in perspective and I think it’s fair to talk about your annual dose which is about 3.1 millisieverts, so you compare that to a bitewing radiograph which is a thousand times less. You keep that in perspective, if they’re just walking outside throughout the day every day they get the same dose…
Howard: [crosstalk 00:49:53] It’s significantly more radiation if you live a mile high like Denver and Phoenix, right?
Howard: Is that significant or not really?
Anthony: I’d have to try to remember but it’s pretty significant like maybe 50% more as they get to that.
Howard: When I go skiing like in the back of Anchorage, or Utah or whatever , you’re up there 10 to 15,000 feet, those are some of the wildest burns you ever got and all that kind of stuff. I only got you for a few more minutes. Any other low hanging fruit that you can tell these guys?
Anthony: Well, what can I think off?
Howard: You’re going to start a thread on your checklist?
Anthony: Yeah, you need to remind me, what threads I’m going to start. Well there are a couple…
Howard: [crosstalk 00:50:32] Yeah I think the checklist one is great. I mean it’s just like brushing and flossing. Every dentist gets that. You brush the same way every time so that when you go in there and you do your blah, blah, blah you hit it all and I think going through the checklist would be a great thing. Another one I think you should explain, how to upload a case, instructions on how to use it, upload it.
Howard: Then another thing, I’m always talking to dentists and another thing is they still struggle with well I’m going to pager once you copy the records. I mean some people are burning them on CD Roms, some people are putting them on these little JPEGs. Do you do any of that? Can you set them on these little thumb drives?
Anthony: You can get pretty huge thumb drives. You can get 4 maybe even 128 gigabyte thumb drives.
Howard: How big of a thumb drive…
Anthony: [crosstalk 00:51:25] For that big they’re pretty expensive but you only need about 500 megabytes or less to fit a cone beam CT.
Howard: 500 megabytes or less and what would the average … When you go to a radio shack and now it’s closed and it’s a KFC but if you go find a thumb drive, what would be the average sized thumb drive and how…
Anthony: The average size probably eight and you can get anywhere from four, eight gigabytes.
Howard: Eight gigabytes?
Anthony: Or 16, 32 maybe even 64.
Howard: How big does it have to be to fit one of those CBCTs?
Anthony: Only half a gigabyte so 500 megabytes.
Howard: You could almost be a practice builder if you put your office name. Can I use dental.com on the deal and then what do you think about that?
Anthony: That’s a great idea. You can get them cheap enough now or big enough to fit at least one cone beam CT and they’ll basically will be cheap enough that they’re throw in ad-ins, so yeah.
Howard: You said CBCT would fit on any of them because you only need a half a gigabyte and the ones that you buy at the store are would you say two, four, six or eight?
Anthony: Four, six, eight. They may go up to 128 gigabytes.
Howard: The smallest one we’re seeing a four, that CBCT would fit on there.
Anthony: Yeah, several CBCTs.
Howard: I think that’s a hell of a marketing and you give a patient a copy of their X-rays, that’s just amazing. I want to ask you another question. A lot of people are looking into instead of having a desktop PC they’re looking into using the cloud and some dentists are talking about, “Well, I heard that’s a bad idea because I’ve got a CBCT and the files are too big to upload to the cloud.” What would you say to that?
Anthony: I don’t think that’s the case at all. I think with cloud storage you can upload huge amounts of data so yes I think that’ll make…
Howard: [crosstalk 00:53:16] Over what period of time? I mean the standard average CBCT, if I was going to buy a practicing management software that was cloud based, how long on the average Internet connection which I think most dentists have whatever their standard cable TV, I think most dentists are using the standard cable Internet, how long would it take to upload that file?
Anthony: I don’t think it would take more than a couple minutes…
Anthony: …Unless you have a really slow connection. Yeah.
Howard: Then that argument is just wrong then?
Anthony: Maybe I’m spoiled, maybe I’ve had the fast Internet ever I’ve gone but I think if you have a decent Internet connection it shouldn’t take more than a couple of minutes to upload a cone beam file.
Howard: When someone sends you a CBCT are you saving all these or do you read them, write a report, send them back, delete or how long do you hang onto that CBCT?
Anthony: Well I save them for now, eventually I probably will move to a cloud storage solution. Right now I have my own server that I save it on so until that gets full I’m just going to save them myself and again I’ll keep a copy of the reports, the referring physician or the referring dentist a copy of the report, a link to a copy of the report. You can’t just email it through the email. It’s not secure but you can email a link to it so they can open it up right off the server.
Howard: Yeah and so…
Anthony: [crosstalk 00:54:30] Yeah for now it’s everything.
Howard: You really think storage is going to be an issue then?
Anthony: I don’t think so. I guess we’ll tackle that one when we get there but storage is getting so much cheaper and cheaper by the day.
Howard: Google this, this is July 1st we’re taping this and Google was it just last month where they slashed their cloud services costs in half?
Anthony: I haven’t heard that but yeah it’s [crosstalk 00:54:57].
Howard: They just slashed it. I believe they slashed it in half, kind of basically telling everybody we’re going big and cheap and fast. Anything else?
Anthony: Well, I think that’s it.
Howard: Do you think we covered everything?
Anthony: I think we did.
Howard: All right, well hey I’ve got to tell you that at 52 my kids are older than yours and my oldest one made me a granddaughter and I just want you to remember that your grandchildren will be a reward for not killing all four of the children so when you…
Anthony: I’ll try to not kill them all.
Howard: When you get to the point where you’re going to kill them all remember there’s a reward and her name will be Taylor Marie and she’ll come many years out of but no I loved every age of the kids. I mean it’s just a fun age but I tell you at 20, 22, 24, 26 it’s even 10 times more fun than they were two, four, six, eight because they’re all…
Anthony: [crosstalk 00:55:56] I’m still just looking forward to when one of them is old enough to babysit and we can actually leave once in a while so.
Howard: Yeah I’m from Kansas, so in Kansas a babysitter was anyone who was one year older than you, so you know those are back in the days without seatbelts.
Anthony: Yeah it’s getting all strict nowadays.
Howard: Well, hey I want to tell you, good luck on starting your own business and I hope that as one of viewers starts helping you with your new business and I hope to see you on the board. I think if you make some online tea courses on how to read it that’d build your brand name quick and all you want is…
Anthony: I’m planning to do that, yeah.
Howard: Right now you have more time than money, so put up some courses there, that’ll build your marketing. I hope this podcast does and it’s kind of funny I go to school in `87 and there were no computers, we just had charts and we thought we were lucky because we felt sorry for the class after us because they were going to computers and we were laughing at them. Then here we are 20 years everybody is computer, everything.
Anthony: Everything is different, yeah.
Howard: Best of luck to you and best of luck on those four babies and thanks for sitting out here with me.
Anthony: Thank you. The pleasure is all mine.
Howard: All right, take care.
Anthony: You too.