Ed Shellard, DDS interviews Mark K. Setter, DDS, MS

You are obviously a big fan of CBCT. What do you wish more people knew about 3-D imaging?
Whenever patients come in for an appointment, we spend some time interviewing them to find out what they want. Almost all patients want to keep their teeth forever. That being said, that requires an examination that is capable of discovering problems that might not allow a patient to keep all of his teeth for the rest of his life; which means that diagnostic and treatment planning can take on a very different perspective. If I had one wish for my profession -- if I could sprinkle magic dust -- it would be to have a good relationship with our patients. You will be surprised to hear how much they do want, and it usually results in more comprehensive treatment planning than is currently being done; therefore, more advanced diagnostics are being performed. That's why cone-beam CT scanning fits within our practice so well.

So you find that utilizing 3-D scans is helpful in patient communication and case acceptance?
As far as practice management tools, one of the biggest obstacles in dentistry right now is to get patients to accept the more advanced treatment options. There are two factors involved in that: (1) understanding what a patient wants and (2) getting the patient to understand what they need. That is where a cone-beam CT scan can come in very useful during the treatment consultation. This is especially useful with periodontal disease -- when you show them the bone loss on an image, they own the disease. If they want to keep their teeth, the three-dimensional views paint a very clear picture of what must be done. Then people get it, and are much more willing to get treatment in a serious fashion, in terms of paying for treatment, showing up for appointments, and doing home care afterwards. That is where I think cone-beam CT scanning has huge capabilities and is being vastly underutilized.

Where else do you think CBCT is being underutilized?
In my opinion, it is extremely underused in determining bone morphology in periodontally-diseased patients, which is a significant portion of the adult population, as well as in determining gingival recessions. Many times, gingival recession is thought to be a soft-tissue problem, and it may well be -- but in a shocking number of instances, it has to do with the underlying bone being inadequate. We are -- in effect -- trying to treat bone loss with gum replacement, when we should be doing bone replacement. A cone-beam CT scan is the way to do that unless you do exploratory surgery. I am understating it when I say it's extremely underused. It's not being utilized really at all in those instances. And it should be.

There are also obviously endodontic evaluations that would benefit from it. For example, one of the most difficult conversations to have with a patient is to tell them that they need to have a tooth removed after they just had a root canal, because the tooth was fractured. And if a cone-beam CT scan is not utilized, fractures may go undetected. Having the wrong diagnosis obviously ends with the wrong treatment, and patients suffer because they end up financing a root canal and a crown and ultimately end up having to have the tooth removed. I don't understand that. It's like treating an ingrown toenail with knee surgery. I think it's underutilized in many different dental applications as well, and so I think the public would benefit from more specialties using cone-beam CT.

How do you think 3-D imaging has changed the way you approach dentistry?
Some dentists treat individual teeth when a patient comes in with a problem; they find out what the chief complaint is regarding an individual tooth, and -- unless they see a glaring problem with the surrounding teeth -- they fix the tooth and it's fine. I'm not saying that's wrong, but dentists who work on a tooth-by-tooth basis may not understand how cone-beam CT scanning can help them.

For the most common problems dentists will encounter, a 2D scan can help if you're dealing with one tooth at a time. But there's certainly a huge trend -- I'm going to include myself and a great many dentists in this category -- of diagnosing a patient's mouth. In doing so, they will take full-mouth series radiographs, they will have comprehensive evaluations, and those people utilize cone-beam CT scanning on a quite frequent basis, either in their own office or an imaging center. After I received my cone-beam CT machine, a number of general dentists in my area got cone-beam CT machines because they realized the number of things you could see beyond what 2D X-rays show and learned that -- business-wise -- it's profitable. It's just better patient care. Better patient care typically corresponds with a healthier practice as well.

It's also more efficient to treat a mouth than to treat one tooth at a time. It's efficient for the patient in number of appointments they need, number of days off of work, etc., but also for the office. If you're treating three or four teeth at one session, instead of one, you're only sterilizing one room and you're only booking one appointment. There are a number of efficiencies that the office gains, which is certainly a better business plan.

We typically treat hard-tissue issues, and hard tissues show up on radiographs. If an office had to function without any radiographs, it would not be a very busy practice. In my view, the difference between having radiographs and no radiographs is equivalent to the difference between having two-dimensional and three-dimensional X-rays, because you just see things you cannot in 2D.

The problem is that dentists think they have seen it all when they have good two-dimensional images, but it's like having a book with covers and trying to pick out an individual page between the covers without opening the book. The things you see in three-dimensional images by taking individual slices through a tooth and the adjacent bone expose way more than a two-dimensional X-ray that has overlap of buccal plate and lingual plate that are extremely thick compared with the subtleties that exist between the buccal and lingual plates of bone. I would say cone-beam CT scanning adds additional diagnostic features that clearly benefit patients' health and that it benefits the practice health as well.

Have you noticed a correlation between the technology you use and your relationship with referring doctors?
How can I put this in bold print and get it understood? Referring dentists refer to specialists partly because they have a good relationship with them and trust them, but they have to have capabilities beyond what the general dentist might. That doesn't just include knowledge -- it has to include technology. You can't be at the top of the food chain without it, quite frankly. So, I would say our office gets some referrals just for imaging -- but we don't advertise that or promote it. We could, but really we don't need to. I would say it positions us as the leader, and not just from a marketing standpoint. We have capabilities of diagnosing things other people can't do. And that's what the definition of a specialist is, really, of having capabilities beyond what the general dentist might. You can't be a periodontal specialist without cone-beam CT scanning and position yourself the way the general dentist wants you positioned. They want you with capabilities above theirs. They don't want to refer to you just because you're a golf buddy; they want to refer to you because you have techniques and capabilities far beyond what they're able to provide.

Mark K. Setter, DDS, MS, is in private practice limited to periodontics in Port Huron, Michigan. Dr. Setter frequently lectures to study clubs and dental organizations nationally and internationally on various aspects of periodontics, dental implantology, and patient management. You may reach him at [email protected].