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CBCT: The New Standard of Care?

By Drs. Christine I. Peters and Ove A. Peters

“I don’t take a CBCT scan of every patient — does that mean my treatment is below the standard of care? I’m trying to save them radiation but could they sue me for that, if something goes wrong?”

The pressure on endodontists to use their cone beam machine before starting root canal treatments or endodontic surgery is palpable, but is an automatic scan of the teeth in question really in the best interest of patients?

Let us take a step back and consider the global situation in dentistry. It may seem like almost every U.S. endodontist either owns a CBCT unit or is on the verge of buying one, but that is not the case in most other countries. Dentists worldwide often do not have access to a scanner in their cities and many still use multiple angle films that require developing. In contrast to 2-D periapical images, CBCT technology has brought the great advantage of revealing 3-D views of the true anatomical situation of a patient. It avoids overlapping structures, distortion or summation of details. Dentists refer their patient for a scan at a radiologist’s office to differentiate pathosis from normal anatomy. However, is it now the new standard of care?

Attorneys define the standard of care as “that which a reasonable health care provider would or should do under similar circumstances.”

Most clinicians agree that it is advantageous and in some instances essential to take a CBCT scan before any endodontic surgery. Precise imaging becomes especially important in surgical cases that might involve vulnerable structures, including sinus cavities, nerve channels or blood vessels. CBCT scans reveal extra anatomy, relationships of structures, traumatic fractures, missed canals, resorptions, instrumentation-related issues such as perforations and help during treatment complications. Accurate measurements can replace certain working images and thus make up for the higher radiation patients receive during a CBCT scan.

3-D imaging identifies up to 40 percent more previously undetectable lesions. What do we do, now that we find so many lesions, and often asymptomatic ones? Does that mean there will an increase in the number of endodontic procedures by 40 percent as well? Pope et al. found that vital teeth vary in PDL width anywhere from 0.2 to 1 mm (1). Are we biased, because a tooth is RCT treated and CBCT shows a widened ligament? Alternatively, are we culpable for not treating such dubious teeth?

Before any impending lawsuit, a patient must prove that an avoidable negligence during treatment was the cause of his or her injury. Judges look for proof that the treatment did not meet the standard of care (2).

Legal cases could also result from a lack of ideal care or treatment. Not noting that a patient refused a recommended CBCT scan before a surgical procedure, for example, can make a clinician lose a court case. A difficult or damaging situation is considered malpractice if it could have been avoided using the right technology and clinical skill.

And this is where cone beam imaging shows its strength. It helps avoid problems by showing the true anatomy of the scanned area. That said the radiation dose is still higher than for a small number of digital PA films. The recommendation is only to use it where there are clear benefits for diagnosis and treatment, including follow-up. About half of clinicians who referred their patients for CBCT imaging changed their treatment plan. Thirty percent of practitioners chose to act instead of monitoring and extracted more teeth after viewing the images (3). It has been suggested that dentists conceive of periapical disease or health on a sliding scale, and lean towards retreatment when the radiolucency becomes medium in size. Teeth can appear flush-filled and healed on the PA but may display an over-filled obturation with a widened PDL on the CBCT. Considering patient-centered outcomes, will retreatment of these teeth improve the patient’s quality of life or their oral health? Some believe it does. However, an argument could be made, that, in some cases, non-intervention and radiographic monitoring is still a good option (4).

To answer the questions posed in the beginning: yes, CBCT may become standard of care for some therapies, but it is not necessary for every root canal treatment. CBCT is not a general screening tool. Doctors can be sued for not ordering a scan that would have circumvented injuries. They can also land in court for not documenting informed refusal. In most cases, it is not enough to talk about it; when in doubt, write it out.

Ove A. Peters, D.D.S., M.S., Ph.D., is a professor and co-Chair of the Department of Endodontics at the University of the Pacific, Arthur A. Dugoni School of Dentistry in San Francisco. He can be reached at opeters@pacific.edu. Christine I. Peters, D.D.S., is a professor in the Department of Endodontics at Pacific. She can be reached at cpeters@pacific.edu.


References

  1. Pope O, Sathorn C, Parashos P. A comparative investigation of cone-beam computed tomography and periapical radiography in the diagnosis of a healthy periapex. J Endod 2014;40:360-5.
  2. Curley AW. Dentistry, the law and CBCT. 2016 [cited; Available from: http://www.dentaleconomics.com/articles/print/volume-106/issue-10/science-tech/dentistry-the-law-and-cbct.html
  3. Mota de Almeida FJ, Knutsson K, Flygare L. The effect of cone beam CT (CBCT) on therapeutic decision-making in endodontics. Dentomaxillofac Radiol 2014;43:20130137.
  4. Liang YH, Li G, Wesselink PR, Wu MK. Endodontic outcome predictors identified with periapical radiographs and cone-beam computed tomography scans. J Endod 2011;37:326-31.

President’s Profile: Dr. Patrick E. Taylor

‘No More Mr. Nice Guy’ Dr. Patrick E. Taylor Shows Some Teeth

By Elisabeth Lisican

You might consider him a nice guy with a “No More Mr. Nice Guy” moxie. Incoming President Dr. Patrick E. Taylor looks forward to his AAE presidency with lots of energy and a no-holds-barred attitude towards elevating our specialty.

Dr. Taylor is on the affiliate faculty at the University of Washington School of Dentistry, where he teaches in the graduate clinic on Wednesday afternoons. His dental career spans 18 years of private practice in Bellevue, Wash.; and prior to that, 21 years in the military, serving in the U.S. Navy Dental Corps, last serving as the executive officer of the Naval Dental Center, Pearl Harbor.

Dr. Taylor is a Diplomate and past president of the American Board of Endodontics. He previously served on the AAE Board of Directors from 2003 to 2006. Dr. Taylor also sits on the Foundation for Endodontics Board of Trustees.

Dr. Taylor did not start out in dentistry; his background includes a B.A. in physiology from the University of California, Berkeley.

“I thought I wanted to be a chemical engineer, but I took a biology class and loved that, so biological sciences seemed like a better fit for what I enjoyed doing,” he said. “My older brother is a dentist, and my older sister is a pharmacist; so, I thought, this is really where I belong — in the biological sciences.”

Dr. Taylor received his D.D.S. from UC San Francisco. His endodontic residency was at the University of Washington, where he earned his Certificate in Endodontics and an M.S.D.

After he became a dentist, endodontics just seemed to make sense.

“I was in the military at the time, and you mostly do restorative work, but you can do a lot of other things; and endo really resonated,” he said.

Early in his career, mentorships were important to him.

“I had some mentors who I wanted to be more like,” he said. “In my initial application for specialty training, I said, ‘all the endodontists I know are nice guys; and I want to be a nice guy, too.’ There were some great women endodontists, too — Drs. Billie Jeansonne and Sandy Madison come to mind — I just did not know them yet.”

Things continued to fall into place for Dr. Taylor. “I knew people who were good role models and they helped me make my way. I have pleasant memories of residency at the University of Washington. The endodontists who were my mentors are still around. They’re not actively teaching so much anymore, but I see them regularly.

“I am very much in their debt and often reflect that I should have listened more.”

Dr. Taylor said that he had many endodontic heroes, but two in particular who had a great influence on him were Dr. Gerry Harrington, the first Bender Award winner, and Dr. Clyde Sabala, from Dr. Taylor’s early Navy days.

Another mentor is AAE Past President Dr. James C. McGraw – whose former practice Dr. Taylor went into in the 1990s. The two plan to catch up at AAE18.

He stays close to his old practice, too. “I still go by the office; I love to chat up the two folks that bought my practice and see what they’re doing. They keep me current.”

When asked what might be the theme of his AAE presidency, he got a bit theatrical.

“Get involved! We can save the world, one root canal at a time! We need to be involved at all levels of the profession: local, state and national – even international, if we can. Collaborate with our specialist colleagues. Go to dental meetings. Come to endo meetings. Contribute to the Foundation for Endodontics – this is our future.”

Perhaps Dr. Taylor’s dedication to the Foundation stems from his own commitment to lifelong learning. He has fond memories of research in neurobiology while at the University of Washington (he won first place in the resident Poster Clinics) and is pursuing a review and continuation of those projects. He has been active in his local dental societies, having served as president of both the Washington State Association of Endodontists and the Seattle King County Dental Society. Fellowships include the American College of Dentists, International College of Dentists, Pierre Fauchard Academy and Omicron Kappa Upsilon.

Dr. Taylor is an avid reader and supporter of the King County Library System, serving on the KCLS Foundation Board and is a past president of that organization. He is also a past president and board member of the UWSOD Deans Club.

Dr. Taylor and his wife Frances live in Kirkland, Wash., and enjoy hiking, gardening and cooking. Their son, Brian, is a physician in the Navy, stationed in Okinawa, Japan, and has an infant son, Luke. Dr. Taylor’s daughter, Katy, is an elementary school teacher in Camas, Wash., and has three children: Chloe, Carter and Claire.

Make no mistake, Dr. Taylor is certainly a nice guy, but when it comes to advocating for our specialty, he suggests perhaps it’s time endodontists cut their “Mr. Nice Guy” routine.

“In the past we’ve always been the nice guys, [telling dentists] ‘you guys should be doing more root canals,’” he said. “I’m of the opinion that it’s time to say, ’No, save the difficult ones for us; enough of this encouraging you to do difficult molars. We should be doing the molars.’

“I’ve had three root canals; they were all done by endodontists … We need to demonstrate more convincingly that root canal treatment done by endodontists is better, faster, less painful and lasts longer.”

Elisabeth Lisican is integrated communications specialist with the AAE. She can be reached at elisican@aae.org.

Gearing up for 12th Annual Root Canal Awareness Week

Root Canal Awareness Week is just one month away! We were overwhelmed by the level of interest and are proud to have more than two dozen practices from far and wide in our legion raising awareness of endodontists. Featured practices are using their superhero kits in creative ways to help us promote this important effort.

Plan Ahead

Even if you’re not a featured practice, there are still plenty of resources available on the RCAW site in the Member Planning Guide. We make it easy for you to promote Root Canal Awareness Week and your practice. Download promotional materials, including logos, social media posts, press releases and videos. There are also helpful tips for using this important week to promote your practice.

Share Stories

We are in the midst of collecting patient stories and photos. Ask your patients to submit their tales via the form on aae.org/rcaw. To assist you in these efforts, we are happy to provide your practice with some promotional cards that direct your patients to our testimonial webpage. All you have to do is submit a request and provide your patients with a card to share a story like this one from Mia Stormski, a patient of Dr. Paula A. Mendez-Montalvo’s, Endodontic Partners, Sugar Land, Texas:

Dr. Mendez is a miracle worker. I went in for a root canal, and the only way I can sum this up is by saying Dr. Mendez is of superb professionalism and true expertise in her work. She pays close detail to the patient, how they are doing before surgery, during surgery and after the surgery. I can’t express in words how happy and grateful I am to have been a patient of Dr Mendez! Just three hours post-surgery, I was able to feel the difference. Pain and pressure had completely become a thing of the past. I feel amazing!!

Shop for Gear

The AAE logo product store is full of great Root Canal Awareness Week merchandise. Place your order soon to be sure it arrives before May.

Keep in Touch

We want to know what activities you have planned for Root Canal Awareness Week and your feedback about the celebration. Email us at pr@aae.org and post your photos to our Facebook page.

Announcing the Winners of the 2018 JOE Awards

The Editorial Board of the Journal of Endodontics is pleased to announce the winners of the 2018 JOE Awards, recognizing the best articles published in JOE during the 2017 calendar year. Thank you to everyone who submitted nominations, and to all of the authors who published their work in the JOE this year. Your contributions keep our specialty strong!

The winning papers represent significant advances in endodontics, and were selected for their scientific merit and broad impact on dental research; originality of research objectives and ideas presented; creativity of study design and uniqueness of approaches and concepts; validity of statistical and/or epidemiological methods; and clarity of presentation.

The AAE proudly recognizes JOE Publication Award recipients and continues the tradition of honoring the achievements and contributions of these individuals to the specialty of endodontics.

2018 Award Recipients

Basic Research: Biology
Zhong S, Naqvi A, Bair E, Nares S, Khan AA. Viral MicroRNAs Identified in Human Dental Pulp. J Endod 2017 Jan;43(1):84-89.

Basic Research: Technology
Connert T, Zehnder MS, Weiger R, Kuhl S, Krastl G. Microguided Endodontics: Accuracy of a Miniaturized Technique for Apically Extended Access Cavity Preparation in Anterior Teeth. J Endod 2017;43(5):787-790.

Case Report/Clinical Technique
Noma N, Hayashi M, Kitahara I, Young A, Yamamoto M, Watanabe K, Imamura Y. Painful Trigeminal Neuropathy Attributed to a Space-occupying Lesion Presenting as a Toothache: A Report of 4 Cases. J Endod 2017 Jul;43(7):1201-1206.

Clinical Research
Schloss T, Sonntag D, Kohli MR, Setzer FC. A Comparison of 2- and 3-dimensional Healing Assessment after Endodontic Surgery Using Cone-beam Computed Tomographic Volumes or Periapical Radiographs. J Endod 2017;43(7):1072-1079.

Regenerative Endodontics
Lin J, Zeng Q, Wei X, Zhao W, Cui M, Gu J, Lu J, Yang M, Ling J. Regenerative Endodontics Versus Apexification in Immature Permanent Teeth with Apical Periodontitis: A Prospective Randomized Controlled Study. J Endod 2017 Nov;43(11):1821-1827.

Honorable Mentions

In addition to the award-winning papers, the following papers have been accorded honorable mention status:

Dr. Robert S. Roda Leads Arizona Dental Association

AAE Past President Dr. Robert S. Roda Becomes 110th President of Arizona Dental Association

Earlier this year, AAE Past President Dr. Robert S. Roda took the reins as the 110th president of the Arizona Dental Association. Dr. Roda’s basic goals for his AzDA presidency include leaving the organization in better shape than he found it, and getting AzDA into a position where it is better able to see and manage the future.

“I am especially proud of our volunteer leaders and staff (especially our execu­tive director, Kevin Earle), who have been working hard for the last 10 years to analyze and help solve the access to care problems that exist in Arizona,” he wrote in a profile article published in the January issue of AzDA’s Inscriptions magazine.

Challenges he plans to tackle in his presidency include “out-of-state special interest groups with uncertain financing and purpose that have been spending mas­sive amounts of money here to push an ineffective concept, the dental therapist, to presumably help enhance access to care,” he wrote.

“The real problem is that our public systems of treatment delivery, treatment financing and especially oral health literacy, need an overhaul. It’s like trying to correct the smoking epidemic of past decades by creating more lung surgeons.”

Other priorities include updating AzDA’s strategic plan: “This process is important to help fo­cus our efforts on what we can do to help our profession and our patients in the future.”

Dr. Roda is an endodontic consultant to the Arizona State Board of Dental Examiners, visiting lecturer in the Endodontic Department at the Arizona School of Dentistry and Oral Health, and associate editor of the Journal of Endodontics. He received his B.S. in Biology (1977) and D.D.S. degrees (1981) at Dalhousie University in Halifax, Canada, and practiced as a general dentist in Nova Scotia for 10 years. He earned his M.S. in Oral Biology and Certificate of Endodontics at Baylor College of Dentistry in Dallas in 1993 and became a Diplomate of the American Board of Endodontics in 1998.

Are Your Investments Appropriate for Your Retirement Goals?

Sponsored Content:
Treloar & Heisel, Inc., is a longtime partner of the AAE and supporter of the endodontic specialty. As one of the AAE’s endorsed vendors, Treloar & Heisel provides members with specialized financial services and advice to guide them through every stage of their careers and into retirement.

Are Your Investments Appropriate for Your Retirement Goals?
Aligning risks and returns to the needs of your financial plan

By Jeffrey E. Wherry 

“Are my investments appropriate for my retirement goals?” The answer is different for every person.

Before you even look at investments, consider your retirement goals:

  • When would you ideally like to retire?
  • What kind of lifestyle would you like to have?
  • Will you work still, a little, or not at all?
  • What active and passive income sources might you have?

Investment returns should fill the gap between your future income and future spending. So, before you decide how to structure your investments, let’s look at your cash flow in retirement.

Let’s look at your spending.

Looking at today’s spending patterns provides huge clues as to what future spending might look like.

Some expenses that people may be currently running through their dental practice may become personal expenses in the future. These include car expenses, and some types of insurance. Some current expenses may not exist at all in retirement: mortgages, debt, and the need to continue saving.

Other, new expenses may take their place. Extended medical care, or other household support, is expensive. There may be more travel and new hobbies.

Now let’s take a look at your income.

Your income in retirement may include Social Security payments, a pension perhaps if you worked as faculty or in a hospital that offered such a program, or rental income from properties you own. If you decide to scale back at work over time, we’ll factor in your (reduced) income into the equation. If you have assets from the sale of a practice, those, too, will be taken into consideration.

The difference between your incoming cash flows, and your projected expenses needs to be filled by your investment portfolio.

Now, let’s see if your investments are appropriate for your goals.

The first thing that we need to do is understand a person’s risk tolerance for investing. We do this by determining their ‘risk score.’ A simple questionnaire, and the use of specialized financial planning software gives us insight into an individual’s tolerance for fluctuations in the market.

Risk tolerance is important is because we want to make sure that the investment program we recommend is within an individual’s range of expectations – for both risk and, commensurately, returns.

We know the markets will go up, and we know the markets will go down. An educated investor knows that if the value of his/her holdings goes down in a particular month or quarter, this is to be expected. Alternately, if a portfolio is doing exceedingly well – beyond expectations – the person won’t get carried away and decide to invest exclusively in those assets that are top performers at this moment in time. The point is to stay the course for the long term, and make suitable adjustments along the way.

We always discuss with our clients, in advance, how they might behave in a bull market (when markets are up), what they anticipate they might do in a bear market (when markets are down), and what could potentially happen in a financial crisis. Thinking through these scenarios helps mitigate what might be a purely emotional response.

Sometimes, the return that your portfolio needs to produce in retirement is greater than what your risk tolerance will allow. At this point, we have a conversation with the client. The choices are to either increase savings, or to slightly ratchet up one’s tolerance for risk. For most people, frequently, it’s a combination of both.

Jeffrey E. Wherry is managing director, wealth management, for Treloar & Heisel Wealth Management. To learn more, visit tandhwealth.com.

Investment Advice offered through WCG Wealth Advisors, LLC a Registered Investment Advisor doing business as Treloar & Heisel Wealth Management. Treloar & Heisel Wealth Management is a separate entity from The Wealth Consulting Group and WCG Wealth Advisors LLC.

This information is for illustrative purposes only and is not intended to represent any specific investment vehicle.

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Digital Outreach By the Numbers – March 2018