HFO CE Radio – Understanding X-ray Dosimetry
As a Hampton Roads referring partner of Hatcher & Frey Orthodontics, we are excited to offer continuing education to our local dental community.
Sit in on this quarter’s digest while industry-leading and board-certified orthodontists Dr. Scott Frey & Dr. Sean Carlson chat about Understanding X-ray Dosimetry.
3 CEUs (Total Run Time – 48:73)
SPEAKERS
Dr. Scott Frey, MSD, DDS
Dr. Sean Carlson, DMD, MS
Dr. Scott Frey 0:00
Hello, everyone, and welcome back to another episode of Hatcher and Frey Orthodontics CE Radio. I have the distinct pleasure of being here with Dr. Sean Carlson. He’s a great friend of mine. He is an expert on our subject matter today.
I want to read a little bit about his bio because he’s got an extensive list of credentials. Dr. Carlson, he’s been practicing in Marin County for over 25 years, and he’s a recognized expert globally for his expertise in orthodontics and 3D imaging, particularly in areas of preventive care x-ray dosimetry, which is going to be our subject today, and airway health.
He’s a renowned digital clinical instructor and holds an appointment as an associate professor of orthodontics at the founder of Simple Orthodontics, an ultra-modern orthodontic clinic in beautiful Larksbur, California, that offers custom orthodontic treatment using a fully digital workflow, and he’s best known for his international lectures on CBCT imaging, early prevention, and the use of modern technology for orthodontic treatment in young patients.
Chat GPT put that together. It sounds great.
Dr. Sean Carlson 01:24
The modern world does better bios than the human one. Thank you.
Dr. Scott Frey 01:28
Fantastic. But yeah, just anecdotally for me, I remember being a student at Pacific and I mean, we go way back, you were the first practice I had visited that had 3D stuff in their office and I thought it was the coolest thing.
Dr. Sean Carlson 01:45
Yeah, and I love it because we go way back and so much of this in my mind and probably your mind is like, well, isn’t everybody doing imaging and dentistry this way? Because I think back when you and I got to know each other, there was this idea that this was going to be widespread everywhere.
Everyone would understand all the things that I’m talking about today. It’s kind of interesting that we’re having this conversation, Scott. I don’t know, it’s over a decade ago when you and I met.
Dr. Scott Frey 02:19
It’s been a minute, huh?
Dr. Sean Carlson 02:20
Yeah, it’s been a minute. I’m thinking, doesn’t everyone know this already? I’m not trying to be glib or dismissive, but this information has been in dentistry for so long and it just takes such a long time to propagate through the profession.
It’s just really hard to move information. So thank you for doing this because I think we’ll reach more people today than me or you going out, getting on a plane and traveling.
Dr. Scott Frey 02:50
Well, I think it’s a great subject for all of the dentists and hygienists listening. Make sure once you’re done either looking at the transcript or listening to this podcast, make sure you fill out the quiz to get your complementary CE credits.
We’ll be posting that in the link the transcript and everything. I’m going to let Sean take it away to cover this subject today. I think it’s super important. There’s a lot of confusion with modern x-rays and modern radiographs. How dosimetry works and how it’s actually gotten so much better while revealing much more information. But yeah, take it away.
Dr. Sean Carlson 03:42
Yeah, thank you, Scott. And I think hopefully we’ll give everybody a few take home messages from this talk because I’ve shrunk it down so we can get into the meat of it. And Scott, since you know this stuff so well, interrupt me as I’m going through it.
Because I think if we have a detailed discussion about it, it’ll make so much more sense. And if you’re a dentist, or if you’re a hygienist, or if you’re an assistant out there, if you’re anything like me, when you went through school, the word dosimetry, like just, it made my head explode because it was just so poorly explained.
And the articles on dosimetry are just mind numbing. I mean, it’s hard for me to find anyone who’s read an article on dosimetry and understood it.
Dr. Scott Frey 04:34
But that’s why we have you do it for us, which is good.
Dr. Sean Carlson 04:36
Well, and the simple part of it is it’s not that complicated. It’s just there’s so many myths and so much misunderstanding out there, but it’s really the, and this slide says it all, it’s the calculation of the absorbed dose of ionizing radiation.
So the thing that most of us don’t know is we are exposed to ionizing radiation all the time. Every day, everything we do, our bodies are built to fight off ionizing radiation. But if you live here in the United States, and I don’t think it’s much different on the East Coast or the West Coast, but it is different the higher elevation you get.
So for those who might be listening at those, the Boulder, Colorado, or the high altitude states, the higher you go, the more ionizing radiation you’re exposed to. But on average in the US, all of us are exposed to eight microceivers a day of ionizing radiation.
Just being alive, we get that every day. The analogy of taking a flight. Again, it has to do with altitude, right? Because a lot of ionizing radiation is just coming from the environment. But if you fly from Scott’s office to my office, and you do a round trip, 60 microceivers of exposure to ionizing radiation, just flying.
And they know this data because they put those little dosimeters on airline pilots and stewards and stewardesses, and they measured it. There’s a reference in this slide, you can actually see the data, the study on it, but just doing normal things that we do all the time, we’re getting exposed to ionizing radiation.
So the real question comes down to, well, how much? And if I put my child, if I get in an x-ray machine, if I’m putting my patients in an x-ray machine, how much extra are we giving those humans? And when does it become really important?
This one I love, because we as human beings, emit ionizing radiation. So if you share your bed, you are getting exposed to 18 microceivers a year of ionizing radiation. So you’re giving that to your partner, and you’re getting it from your partner.
So there’s really no escaping this. Ionizing radiation is everywhere. The real question becomes, what is too much? And when should we start to get concerned? So the ICRP, which is the governing body of x-ray dose, they’re the ones that control what is safe to give to humans.
So the ICRP says, limit your exposure to 1,000 microceivers a year. So don’t expose your patients to more than 1,000 microceivers a year, and you’re well within the safe zone. So I want you to keep that number in mind, the 1000 microceivers, right?
That’s kind of like the FDA, right? They say, oh, you’re not supposed to have this much stuff in a can of beans, or it’s unhealthy, right?
So this is what they’re considering that healthy zone, 1000 microsieverts per year, all right? If you go to the medical literature, and these are the cancer institutes, everything studying medicine, medical imaging is way higher, right?
But here’s the data around medical imaging. There is no data that unequivocally says there is a higher occurrence of cancer if you’re exposed to anything below 100,000 microsieverts. So put these numbers in your head.
So the medical bodies are saying we have no evidence that x-rays cause cancer, anything below 100,000 microsieverts. So if you’re exposed to 100,000 microsieverts, or less, there is no evidence out there that says your incidence of cancer is higher.
Scott Frey 09:03
Is that a yearly dose or is that kind of like a total, that’s not a total lifetime dose?
Dr. Sean Carlson 09:09
So this is for the studies that we have the biggest studies we have are X-ray studies, but more importantly Hiroshima and Nagasaki and I know it sounds terrible, but that’s where the biggest ionizing radiation studies come from is nuclear studies, right? So there’s plenty of people that were exposed to 10,000 times this who are still alive from Nagasaki, Hiroshima, all those sorts of things.
So the epidemiologic data that we have on ionizing radiation is limited statistically just because these numbers don’t show increase in disease. So it’s basically saying if you look at all the science, we can’t unequivocally prove that if you’re getting anything below this dose that you’re going to be at higher risk for cancer.
So that’s just the data. We just don’t have it. So keep in mind that previous slide that I just showed you. The ICRP says don’t do more than a thousand, right? The medical literature is kind of saying well, don’t do more than a hundred thousand.
So here we are as dentists, patients, friends, family, all that sort of stuff and we’re going to put a child or a patient in an x-ray machine, whether it’s a 2D x-ray machine or 3D x-ray machine, we’ve kind of put these parameters on it, right? Don’t give me more than a thousand a year and there’s nothing that’s going to prove my risk rate is higher under a hundred thousand, right?
We know we’re getting exposed to eight microsieverts a day just living. All of the dosimetry studies that we have in dentistry, the best ones I know of, come from this guy, John Ludlow, and so there’s these two papers that are great. We’re going to talk about this 3D paper, which is also really great. But this talks about how much ionizing radiation your patients are getting when they step into these machines. So if you do a PA or a bite wing on your patient, you’re going to give them a certain amount of ionizing radiation. If you do a panoramic x-ray, a 2D panoramic ,you’re going to give your patient a certain amount of X-ray ionizing radiation. A bite wing is typically five microsieverts. If you just snap a bite wing of a patient, you’re exposing them to five microsieverts of extra dose. They’re getting eight that day. But if you take a bite wing, you’re gonna give them an extra five, right? The goal is we don’t want this to add up to more than a thousand in a year to stay in the safe zone.
So 3D imaging sadly gets this bad rap that oh, well if you put them in a 3D cone beam machine, you’re going to be exposing them to just tons more ionizing radiation and it’s absolutely not true. So Ludlow, who studied this in detail, used what are called phantoms. So instead of putting people in these x-ray machines, they put these plastic rubbery simulations of people. These phantoms have bone soft tissue, all the things that a normal human would have, but you can put these little x-ray readers inside the phantoms. You can just image them all day and see how much is actually absorbed by the specific tissues. What’s really cool about the Ludlow studies however, the one that I referenced on that previous slide, is they compared a child phantom and an adult phantom. This is important in that children have different anatomy placement, and so they are exposed to a different level of ionizing radiation versus an adult. So you just want to be mindful of that. For Ludlow, he did children and adults and he compared the data. I’m not sure what you do Scott, but I know you do 3D imaging, this is typically the 3D image that we capture on a hundred percent of our patients. It’s typically a full head CBCT 16 centimeters by 13 centimeters.
Scott Frey 13:33
Yea, we do that as well.
Dr. Sean Carlson 13:35
Okay, so most people if you just told them if you talk to a hundred hygienists and a hundred RDAs, they would say oh, well, that’s a ton more x-ray exposure than you know, my 2D pan and CEPH, right?
Ludlow found this is 11.4 microsieverts for an adult and 17 and a half for a child. So, a panoramic x-ray, a digital pan, is 25. If you do a low-dose CBCT, 3D x-ray, at the lowest dose, you’re going to expose it to less than a pan.
Scott Frey 14:21
Now let’s put this in perspective for the listeners. How are we getting to this really low dose, because 2D pan, which gives me very limited information about impacting canines and things like that is more than what we’re now using for the majority of our patients with these quick scans. What is the voxel size? What’s the resolution on that scan? How are they arriving at that? Is it just algorithms or other kind of technology within the machine?
Dr. Sean Carlson 15:04
Yeah, so if you’re using a low dose scan, then the voxel size is 0.4 millimeters in resolution. The smaller the voxel size, the higher the exposure. I think the best way to think about it, Scott, is not so much the resolution that you pull out of it, but what you’re going to be using that image for, right?
And so with panos, what you need to understand is panoramic x-rays use a fan of x-rays. They shoot it at the patient and it spins around the head in three dimensions. A CBCT uses a cone, the same way a periapical x-ray does, a cone of x-rays that spin around the patient.
The reconstruction of the 3D volume that you see on the screen is based on how many pulses of x-ray get shot as you spin around the patient. So the algorithms that reconstruct a three-dimensional head from all those pictures are getting better and better.
So even with low dose scans, the ability to view three-dimensional structures is really great at 0.4 voxels. Now even if you bump these images up and you want to get a higher dose and you start getting into 60-75 microsieverts, I really want the take-home message to be how small that is.
Remember, a thousand is your limit for the year, so you could take, you know, what is that? That’s a hundred low-dose, full-head CBCTs and not get to a thousand. You could take probably 15 higher resolution CBCTs and still not be close to a thousand.
With panoramics, you’re doing 25 per image, so again you’ve got 40 pans. So the real important take-home, and I’ll get to it at the end of this presentation, is that a thousand is teeny, teeny, teeny, teeny. One hundred is teeny, teeny, teeny, teeny. Seventeen is very, very, very small. So if you’re taking these images, understand what you’re imaging for. Image at the lowest dose you can to get the information that you need.
But even when we talk about ClinCheck and integrating 3D image into an aligner setup, you don’t need a high-dose scan to do that. And there’s a lot of power even in low-dose scans.
Now I know a lot of doctors do progress images where they evaluate third molars or root alignment. Typically, we would do an eight by eight scan. That’s five microsieverts for an adult and seven for a kid. That’s a bite wing. A three-dimensional scan of a patient’s teeth, which means you can put that entire data into a 3D Invisalign ClinCheck or a 3D integrated aligner, whatever software you’re using for the cost of a bite wing exposure-wise. That’s ridiculous, to me.
Scott Frey 18:43
Yeah. I’m glad you got into that aspect of the cone-shaped beam versus the fan-shaped beam, because the way that this beam is shaped is having an impact. The algorithms are having an impact, and all of that is bringing this even lower with way more information than typical x-rays that we’ve been doing in the past.
Obviously, you can dial up the resolution and it would be a larger dose, but for visualizing bulk structures and bone levels, joints and things like that, we’re getting a lot with these low-dose scans.
For perspective, when we talk about the size, this 13 by 16 centimeter size, we’re talking about basically from the forehead down to mid-neck, we’re getting airway, we’re getting all the joints, the jaws, the soft tissue facial structure, all of that in these size scans. So that’s a tremendous amount of data.
Dr. Sean Carlson 19:47
It’s a tremendous amount of data and I’m glad you brought that up because most humans fit in a 16 by 13. And you get all of that bonus content. It’s funny when I talk to doctors, one of the biggest challenges I have when I start talking about 3D imaging versus 2D, dosimetry questions aside, even if you get that dosimetry question answered, a lot of doctors will say, well, I don’t want to be responsible for all these things that I’ve acquired, But the kicker is this, it’s on your CEPH, you’re responsible for it, it’s on your pan, you’re responsible for it. It’s way harder to see on those two images, but you’ve imaged the same structures. It’s just with a 3D image, now you can actually see everything. So liability is one of those things that you’re imaging the full head the whole time. So it’s an interesting point where we get hung up as clinicians and technicians.
Scott Frey 20:58
Well, I remember there was a legal opinion on this. Where they looked at liability and I guess the determination was by doing 3D, it actually de-risked your practice because you had clearer visualization of abnormalities. I mean, with the shadows and stuff on the two-dimensional ones, it’s very difficult sometimes to see everything. Like, you know, if there are tongues in a different spot, sometimes even extra teeth, it’s very hard to visualize on the two-dimensional scans.
I mean, we don’t even need to necessarily take earrings and stuff out on patients that don’t want them out because they’re not going to get in the way on these 3D images. But the study was looking at liability, or actually the legal opinion was looking at liability. And if I recall correctly, what they said specifically is that we are responsible for diagnosing things in our scope of practice. So, I mean, and this gets into like other areas of dentistry, but like our scope of practice doesn’t change. So any image that involves our scope, we have to look at it. But are we supposed to be diagnosing brain tumors or things like that? No. If we see something abnormal, it gets pointed out and sent out and stuff like that.
Do you use beam readers for that? We use that.
Dr. Sean Carlson 22:23
I have in the past, I don’t now. And I would say for any doctors getting started in cone beam, if you want to learn a lot about anatomy and what’s going on, yes, and send every case to a radiologist, the first 100. Send it back, get the reports back, read through them, and you will be better at reading 3D images than most doctors, physicians, dentists, whatever. If you do 100 radiology reports, you’ll know pretty much most of everything that’s going on in the head and neck.
Dr. Scott Frey 23:05
We rarely send but it’s like if we see something really weird, just to get the patient report. We’ll refer now and then we’ll send us out. I think it costs like 130 bucks for a full report. They’ll do 2D as well, the radiologists, but we’ll send things out just for the peace of mind when we see something truly odd on there
Dr. Sean Carlson 23:26
Yeah, and it’s easy right now that it’s digital you can send it out. I tell you Scott I know we’ve had these conversations about the future and you know where AI is taking us, but AI is gonna read these better than radiology. Guarantee, five ten years from now. Well, man. Wait, you have a human read that? Are you kidding? Why? The computer is ten times better at reading it! So technology is advancing so quickly that I think our risk is less by imaging in 3D. That’s my personal view.
So, let’s kind of jump up to what I think is kind of the real powerful take-homes in this and this was Gosh, this is 11 years ago. I used to put this quote up and, I thought oh, this is going to completely change everything about orthodontics, right?
Because this is from that Ludlow Reference that I put earlier in the slide deck. Ludlow, a dental radiologist, is saying that these quick scan plus protocols that I described are less exposure than combined doses of Modern 2D pans and CEPHs.. When this came out at the time I just thought it was going to explode orthodontics because most orthodontists do pan and CEPHS and here Ludlow is saying, just get a cone beam and do one scan and you can do it in less like that is to me just groundbreaking and so interesting.
Scott Frey 25:20
If it cost less than people would have less of a problem with them. I mean, it was a substantial investment for us to get these machines into the office, but I think that’s probably when people look at the dosimetry stuff or claim the dosimetry is a liability. I think they don’t want, at least in the orthodontic world, they’re like, yeah, I’m happy with my 2D and not having to spend. I couldn’t practice without it, to be honest.
Dr. Sean Carlson 25:51
I couldn’t either and I often joke if there’s one thing you can’t take away from me, it’s my cone beam. Now if you take away my Lumina scanner, I can’t work.
It’s pretty amazing where we are. So, these next few slides sum up everything. If I could just put this in everyone’s head that’s out there in the dental world, whether you’re a practicing dentist, orthodontist, assistant, REA, hygienist, whatever.
So those first slides, remember I talked about the medical limit being a hundred thousand microsieverts. The ICRP limit being a thousand microsieverts, which you’re seeing on this slide, and then what I put here next to it, just to give you visual perspective, is like I don’t care if you’re practicing in a 2D world or a 3D world, I want you to appreciate how little exposure you’re giving a patient when you image in 3D and compare that with the ICRP’s limit.
This is showing three subsequent images in a year. I just stacked over on the left-hand side. Let’s pretend you have a patient and you’re going to image them in a cone beam machine three times during a year, full volume. What you’re going to see over on the left side is those little stacks are what you’ve exposed your patient to. That’s three full images. The bigger stack, the ICRP limit, you can notice that you’re so inside of the safe zone that it’s really hard to see that you’re exposing your patients to any considerable risk.
Scott Frey 28:03
Now let me ask you this while we’re sitting on the slide. They recently updated the regulations to say that you don’t need the lead apron anymore. Was it this kind of stuff or has it just been an ongoing conversation with that? Because we’ll still, because we have them, still put them on. It’s more of a theatrical thing, even though we know that it’s really not a huge thing.
Dr. Sean Carlson 28:31
I honestly think it’s in my understanding of dosimetry and going really deep into that data. It’s been a theatrical thing from the beginning. I just think it is this idea of making people feel more comfortable about a worry that’s non-existent. So my personal belief is it’s probably been nonexistent for forever.
Dr. Scott Frey 29:02
Oh yeah, the dosimetry hasn’t changed, but it’s just funny how all of us have been.
Dr. Sean Carlson 29:08
The actual reality of the science has not changed. And again, remember our bodies are built to defend against ionizing radiation. So this slide, if you look at that red column, this is what your body is exposed to all year of ionizing radiation. That’s just living, that’s just being alive. Your body is fighting off any negative effects of that big red column, it’s doing a really good job. And believe it or not, if you dive into the medical literature, there was an argument way back, I think it might’ve been in the 40s or something, where physicians were exposing their children to a chest X-ray as a protective measure.
I kid you not, they used to say, oh, well, it’s like teaching the cells to fight off bad stuff. So we’re going to give it a chest X-ray, not that I’m advocating that, but I’m saying it’s kind of like you’re pushing the body system to get rid of bad stuff.
I think the take home message of this slide is your body’s really good at fighting ionizing radiation and taking care of those cells that may get damaged by the sun. But these teeny columns where dentistry lives over on the left-hand side of this slide are almost negligible.
And when you see it in a graphic perspective like this, it makes a little bit more sense how teeny these exposures are. But this is the slide that really hits home because this is the cancer studies saying, hey, look, anything below this big, huge line of a hundred thousand microsieverts is small.
So notice how that natural exposure, the red line, got teeny because most people aren’t getting cancer from just being alive out there and living in the sun. So it’s just teeny, teeny, teeny.
So it’s good to understand it. It’s good to understand what quantification is. It’s nice to put numbers to 3D scans or pans. But I would really argue, don’t get into the competition of, 10 microsieverts is better than 15. We’re all living in a very safe zone in dental imaging. And you kind of hit the nail on the head with the lead apron, right? Because the medical industry just came out and said, you don’t need to do that. You don’t need to put those on your patients anymore.
Scott Frey 31:50
I don’t know whether it was in JADA or it was in one of these dental blogs or something like that. They had an obstetrician write in basically just laughing. He was like, I get these dentists asking me if it’s OK to radiograph a pregnant woman. He was like, yeah, it’s fine. Put a lead apron on if you want. But ask yourself, is the radiograph really necessary? I mean, if it’s something you can delay, that’s the goal. It’s the ALARA principle. If you don’t need to do it,you shouldn’t do it. So you can wait. I mean, 40 weeks is not a crazy long period of time. You can wait a little bit if it’s not that important. But if you do need an x-ray for something, a medical procedure, a dental procedure that’s life threatening, like a major infection or something like that, and you need an x-ray, you’ve got to take one. I just thought it was funny, the article, because he was really condescending.
Dr. Sean Carlson 32:59
It is interesting, depending on what side of the conversation you’re on, which is just human nature, you’re going to say don’t ever expose a pregnant woman to x-rays because we know ionizing radiation has potentially negative consequences. So if you don’t have to do it, don’t do it. But, like you said, if it’s life-threatening, oh, you bet. If a pregnant woman comes into the ER and they need to do an image, they’re going to do an image because you have to think about it, well, what’s the upsides and downsides?
But what’s very interesting to me, kind of when we talk about dosimetry and what cuts more to the human nature argument of it, is I showed you that slide about air travel, right? Why do you think that’s not in the news that pregnant women shouldn’t fly because they’re going to get 60 microsieverts if they go to the west coast and back. That would kill the airlines. But if you’d give her a cone beam in your office, you’re way less than a trip between my office and yours. So it’s just kind of how the human mind works, you know?
So there you go. Hopefully that puts 20 or 30 dosimetry articles into something very simple. There’s not a lot to worry about here.
Dr. Scott Frey 34:40
Fantastic. If you can send me some of the links, I’ll put those in the description so people can find those and read the entire study if they’d like, or if they have interested patients who are asking where are you getting this information from, right?
I mean, we’re pretty credible people, but you know, we might as well cite the literature a little bit! But let me ask you this, right? So I think I know what the answer is going to be, but we both have iCats in our office and, and we prefer that particular model for orthodontics. But as far as endodontists, periodontists, oral surgeons, dentists out there that might be considering buying a machine that either has 3D capability or is just entirely 3D, what would you recommend the average buyer look to make those decisions? And what should they be asking these manufacturers when they’re evaluating products?
Dr. Sean Carlson 35:53
I think the biggest thing to ask is, ask yourself why you need it, first off. And you and I both have iCAT machines, and there’s reasoning behind that. And I think the CBCT machines that are out there on the market. Currently, they’re all very good at 3D imaging. I think the biggest thing to look at is, number one, what volume area do you need to image? I always say go for the biggest volume area because it gives you the biggest area to image. So if you’re a practice that only does endo, your tendency might be, I’m going to get a small volume machine. So I can just do my endos. There’s probably going to be a situation where you want to do a full head image. So in my mind, you can always go smaller, but it’s very difficult to get a machine that’s small and then try and image bigger. So I say look at the volume of area that you’re going to image and buy the biggest machine or the biggest image area volume, because it gives you more versatility.
I think all of the machines perform the task of capturing 3D data. My biggest argument would be just get a 3D machine, whatever you do. Any machine, make sure it’s 3D because I just think you’re throwing away valuable data by imaging in 2D in today’s modern world.
Just get a cone beam machine, whatever you do. And I think there’s lots of places to buy really good machines. But I’d say if you don’t have one of those in your office, put that on your budget for 2025 and get one.
Dr. Scott Frey 37:52
The workflow for us, that’s part of probably why, I know for us, that’s one of the reasons why we got it apart from the quick scans and all that good stuff. Once you get into the dental space, you really can’t go wrong like you said. Depending on what software you have and what’s integrated, that may be the bigger factor for individuals when it comes to that.
Dr. Sean Carlson 38:18
And that’s a really good point, Scott, because I think for a lot of doctors, it’s intimidating. If you’re used to your 2D imaging world, stepping into the 3D world is a little bit scary because the file types are different. How you read it with software is different. How you send it to a referring doctor is different. I mean, those protocols are quite easily solved. And I think you solved them all. I’ve solved them all.
They’re not daunting. They just require a few weeks of adjustment and retraining your team to do it. But once you get in, you can’t go back. You can never unsee these 3D images. And so getting through that hurdle is important. And know that it’s going to be a little uncomfortable when you first jump into 3D. But that discomfort lasts for a very short period of time. I mean, I don’t know. How long did it take your team to adjust to a 3D imaging world?
Dr. Scott Frey 39:26
I think it helped when we got the majority of the offices with them. When we only had one office with it, they were so used to just importing it in. But with the 3D, it’s a little bit different process for that. So, I think the bigger thing was not necessarily the length of time, because each one of them could do it within a week getting used to it. But being a predominantly 3D imaging practice, only one of the offices doesn’t have one and that’s just for now. But basically, when we had it pretty much everywhere, it’s just that muscle memory was so easy for them after they picked it up.
Dr. Sean Carlson 40:16
Right. And you can, as you know, for the doctors that you still work with that are 2D, like the extracting pans and CEPHs is a no brainer in 3D.
Dr. Scott Frey 40:31
I mean, to put on a letter or something like that we’ve got to convert it over to 2D. So there is a process in there, and we will send out those kinds of constructions as well. Is this is your last slide on this subject, right?
We were looking at a case the other day with Invisalign, integrated with the talk about today. Do you have that? Could you pull that up?
Dr. Sean Carlson 41:35
So this is, and I know you do some 3D integration too, but a typical ClinCheck for us is 3D integration of roots. And this to me completely changes the way I treatment plan. And I’m looking from roots up, not crowns down. So in a way when I treatment plan, I’m treatment planning from the apex just as much as I’m treatment planning from the crown. And with integration like this, why would we not look at all the roots and make sure that we get those roots parallel?
Scott Frey 42:24
Well, that’s the funny thing I’ve noticed too, is on some of these cases, if you have a really significant dilaceration, especially like a labial dilaceration that would sneak up on you on a two-dimensional x-ray, having that knowledge here, you can understand how to position the route ahead of time to help with some things.
People get really hung up on how the bone responds in these cartoons. It’s not accurate. The bone adapts really extraordinarily well. Some of this reconstruction is more a figment of the software’s imagination than anything.
The underlying enabler route to get a bite corrected, is there some weird anatomy that’s obstructing things? All of that kind of stuff. That’s a huge help and it’s a huge time saver, at least orthodontically.
I’m sure that you’re seeing the same thing.
Dr. Sean Carlson 43:23
It’s a huge time saver. And I tell you what I’ve discovered, Scott, especially with aligner treatment, or if you’re using all digital workflows, like KLOwen and Lightforce, in an all digital practice, the roots rarely have to move very much.
And I think this is, going back to my analog days, my biggest problem was I moved roots into the wrong place and had to move them back. So when I look at cases, and this one on the screen is a good description, if you look at the root apices, how much the roots actually move, it’s just not very much.
And I pretty much diagnose from the root apices. And if you look at malocclusions, where this is a good example of this lower anterior crowding, and the crowns are all over the road, but if you look down at the roots, they’re really not all over the road. So if you treatment plan from that perspective, you actually realize you’re just up riding flagpoles, basically.
Scott Frey 44:48
I sat next to, most people won’t know who he is, Larry Andrews, right? So you and I know who he is, but he’s the guy who invented a straight wire kind of appliance with the prescription brackets and all that stuff. And he says the exact same thing that you’re saying right now, which is basically these teeth develop inherently in the right neighborhood and there’s very minimal corrections that we necessarily need to do to get things into the functional position in the vast majority of people. There’s so many people, like when I’m educating other orthodontists on aligners or you know really anything, I think there’s so many things that people are making their life so much more difficult because of a lack of understanding about what they’re actually moving and what the goal should be This is huge because you have all of that there if you need it and I think they’re going to get the landmarks a lot better simply because they’ll know where the long axis is on these teeth.
Dr. Sean Carlson 45:54
I’ll tell you Scott, I’m one of them. I’m one of them that was working way too hard for the first half of my career. I didn’t know it, but you can’t see the forest from the trees, especially with the way we’re brought up and trained through this profession.
Larry Andrews was on to something. I’ve got a slide that I put up which is exactly like your conversation with him where he says the amount of tooth movement from A to B, from malocclusion to final occlusion should take no more than six months. The reason it takes more is because we go off on all these side tangents and then we have to find our way back to where we were. So he’s quoted as saying, this is Dr. Andrews, you know, one of the smartest guys in our profession. He says orthodontics should not take more than six months on most patients. And I know we’re all fighting for that holy grail. I think we’re getting better. Like with digital workflows, I’m getting much more efficient at getting people there faster because I can see things.
Dr. Scott Frey 47:18
It’s just eliminating those detours. That’s key. Obviously compliance is such a huge factor in what we do as well. And that’s probably, I mean, everybody could be done and probably that six-to-12-month timeframe if they were really on it. But that’s not everybody, it takes some people longer to find that rhythm. So I’ll still tell them 18 months knowing that it’s going to finish a lot sooner if they get it.
Dr. Sean Carlson 47:44
Yeah, and I mean again, I think all of us would love to finish in six months.
Dr. Scott Frey 47:52
This has been awesome. I think people are going to love what we covered here today. It was fantastic. Integrating that little picture of the Clincheck here with the roots, with the bone, super fantastic.
We’re going to get this posted up. Make sure that you take the quiz, get that CE locked in. It’s super easy. But thank you for coming on today, Sean. It’s been a pleasure.
We’re going to have to catch up soon. I’m going to have to get my 60 microsieverts and get out there and see you in California.
Dr. Sean Carlson 48:30
That’s right. Likewise. Thank you, Scott. Appreciate it. Take care.