Episode #640: How To Properly Read Cone Beam Images, With Dr. Dania Tamimi

Bones chronicle a person’s life, and imaging helps you to read it. Knowing how to properly read the imaging is critical, and Kirk Behrendt brings in Dr. Dania Tamimi, lead author of two textbooks, Specialty Imaging: Dental Implants and Specialty Imaging: Temporomandibular Joint and Sleep-Disordered Breathing, to encourage you to use imaging when diagnosing your patients. Imaging is like having a crystal ball! To learn how proper readings can change your patients’ lives, listen to Episode 640 of The Best Practices Show!

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Links Mentioned in This Episode:

Read Specialty Imaging: Dental Implants and Specialty Imaging: Temporomandibular Joint and Sleep-Disordered Breathing

Read Specialty Imaging: Dental Implants

Register for Dr. Tamimi’s courses BeamReaders

Learn more about Modjaw

Main Takeaways:

Imaging helps you see the past, present, and future of your patients’ dental health.

Understand the physical, emotional, and psychological causes of dental issues.

Change the trajectory of your patients’ lives by understanding bone biology.

Be smart about who you irradiate and use imaging when it’s necessary.

Remember that bone is alive and “fluid”.

Quotes:

“When we’re looking at the imaging, when we’re looking at cone beam CTs, panoramics, or whatever, we’re really thinking about the process of how this person got to that point because your bones are the chronicle of your life. Your body is the chronicle of your life, in general. But when we’re talking about cone beam CT and imaging, in general, in dentistry, what we see is the bones, the hard tissues and whatnot. These tissues basically will record your life instances — what you do with your body, how you hold yourself, how you carry yourself, how you function, how you chew. All that stuff will reflect on what your bones look like on imaging.” (4:23—5:05)

“I’m looking at people’s skeletons and trying to figure out where they were in the past, what happened to them in the past that brought them to this point in terms of morphology and function, and then what do I see in the scan here that can change their morphology and function in the future. So, it’s kind of like looking into a crystal ball. You look into the past, you look into the future, and you try to figure out what’s going to happen to this person.” (5:10—5:35)

“If you understand bone biology, if you understand how osteoclasts and osteoblasts interact with one another and how bone remodels in response to function or parafunction, if you understand how the face changes when someone doesn’t breathe properly through their nose, then it’s easy for you to put all those pieces together and help change the projection of that person’s life.” (6:56—7:21)

“If you ask me what the most misunderstood structure is in the craniofacial complex — and the most important to understand — it’s the TMJ. All of us have gone through dental school. All of us have had some semblance of TMJ education in their background. But unfortunately, most of us have had a very poor introduction to TMJ, a very poor understanding of how those joints function. And when it falls into disrepair, parafunction, dysfunction, whatever it is, that’s going to change the way your occlusion works. That’s going to change the way your teeth fit together. It’s going to change the way your face forms and grows. It’s also going to affect the patency of your airway.” (7:53—8:41)

“There’s someone who’s coming to you, and they say their teeth don’t fit together anymore. They basically have a gap in between their front teeth, an open bite. You’re thinking to yourself, ‘All right, let me do some Invisalign to try to bring those teeth together.’ But no, that’s not the way to approach these. If you see a bite change, you have to understand why. If you see crowding of the teeth, you have to understand why there’s crowding of the teeth. It didn’t just magically happen overnight. There’s a process that led us to that point, and it’s not just bad genes. It’s a process of how the housing that held those teeth or holds those teeth is no longer where it should be. It has changed over time and created these bite changes. So, an open bite, if you have a patient who had their front teeth together at some point, and then they came to you and say, ‘Hey, my teeth aren’t together and the mamelons are worn off,’ then you know that there’s something going on with the TMJ. So, that’s going to be your first thing to think about.” (8:49—9:52)

“I try to make the TMJ relevant to the everyday dentist, to the general dentist, to the specialists. It’s not just about, ‘There’s a clicking joint. All my joints hurt,’ whatever. There’s a whole bunch of things to consider. A lot of our dental work needs to be proceeded with a good TMJ evaluation and airway evaluation as well — and my take on this is the radiographic evaluation of these patients — so that, in the end, your dental treatment survives long term. You want something that’s stable. You want something that’s going to last for a good chunk of that person’s life and not fail because you misdiagnosed your patient. And that right there is a point that I see, that we shouldn’t be diagnosing our patient’s teeth. We should be diagnosing our patients — a full, comprehensive evaluation of their craniofacial complex that houses their teeth — so that when we render dental treatment, we should be able to do that in a fashion that we have stable results that hold with that patient for a good chunk of their lives.” (9:54—11:13)

“We have to come to a realization that bone is alive. We tend to think of hard tissue as something that’s solid, that’s unmovable, when in reality it’s fluid — or, it’s not liquid. It’s fluid, meaning that it will move over time. It will change over time. That’s the homeostasis that we, when you understand how osteoblasts and osteoclasts work, and the modeling and the remodeling, and how these things can work together to suit the function and to suit the everyday habits and patterns of movement, then you understand that whatever you have right now, your morphology right now, it’s not going to be the same in 10 years. There’s going to be a turnover of the bone. There’s going to be a turnover of the tissues, the structures, the soft tissues, and hard tissues. All that is going to interact with one another as a result of how you use your body.” (11:57—12:53)

“Where were we like 25 years ago when you and I were in dental school? We were still doing panos and cephs. We’re still doing these procedures, but now we have the ability to actually view our patients in 3D. You and I are three-dimensional structures. Our patients are three-dimensional structures. Their teeth inside their mouths are three-dimensional structures housed in three-dimensional structures. So, it makes sense for many of our procedures to be able to visualize those three-dimensional structures in their true dimension in 3D. Maybe in the future, we’re also going to be able to see them in 4D moving with time. But definitely, there is movement towards improvement towards advancement. I don’t have a crystal ball. I have 3D vision. I don’t have ESP or anything like that, so I can’t tell the future. But just by watching the progression of imaging over the past 20, 50 years, look at how far we’ve come.” (14:31—15:42)

“Many of our dental friends, even though they work in 3D, they’re not looking in 3D. And there are a lot of misconceptions or fear of the use of radiation — which is justified. Photons are bad. But the thing is, whenever we acquire an image or make a decision to acquire the image, there’s a thought process that we need to be considering. The first is, can I get the diagnostic information I need without using X-rays? If I can do that, then I don’t do that. I don’t even go for a periapical if I don’t need it. But if your diagnostic evaluation, clinically, is insufficient to render the correct diagnosis to your patient, then you need to bring out whatever big guns you have and do that judiciously. Screen your patients. See what they need. So, I guess the misconception here is, we are going to stay away from cone beam CT because it’s such a bad thing because of the radiation. Yes, radiation is a force to be reckoned with. But the thing is, in my humble opinion, the harm that you do by not diagnosing your patient properly far outweighs and is far more prevalent than the harm that may occur with some random photon hitting a water molecule and ionizing it, or any of the other changes that we see with imaging.” (15:58—17:38)

“One misconception that I’d like to, or at least one fear that I’d like to quell is, yes, we have to be very smart in who we irradiate. But we shouldn’t be so scared to use imaging when we really need it. Many of the cases are the three-dimensional movement of teeth. In the case of orthodontics, surgery, if you’re going to be removing a third molar and the canal on the pano is ambiguous, definitely, you’re going to need to see where it is so that you can maneuver around it. Things like that. And, in general, I believe that most orthodontic patients should be seen in some way or the other in three dimensions because the 2Ds are not sufficient to really represent that patient’s morphology. There’s also magnification, super imposition, lots of things. And because I see a lot of these patients, I see the resorptions — I see the pathology that would otherwise be missed on 2D. That’s why I’m like, don’t worry too much about it. Just be smart and use a good selection criteria when choosing who to acquire an image for, be it cone beam CT or other.” (17:40—19:06)

“[4D is] the dimension of time. I’m looking at you right now. I’m looking at you 10 years from now and I’m evaluating what’s happening with your progression. And to be able to monitor that with time in a more fluid manner, you can also introduce another dimension, which is movement. Obviously, our jaws are not static. Our TMJs are not static. They have a certain trajectory to how they work, and everybody is a little bit different because they have different conditions that may affect the way that they use their mouths, their jaws, their lips, their musculature, or even their head posture on their neck. All that changes how you move. So, watching the movement and the function, over time, those are the extra dimensions. 3D is just the image itself, the static image. The fourth and fifth dimensions would be time and movement.” (19:20—20:30)

“AI is coming. We’re not there yet where the software is going to replace the radiologist. It is an aid, at this point. Not in the oral maxillofacial radiology quite yet, but in medical radiology when the evaluation necessitates a static lesion. So, the variation in the grayscale of the units that make up the scan, which are called voxels, the AI can pick up patterns of change that alert the radiologist, ‘Hey, there’s something here. Take a look and tell us what you think.’ So, it’s still done in conjunction with a human. It can’t be that you just rely on the AI. It’s a tool to help minimize things like errors that come with fatigue, for example. Someone who’s been on-call all night and doing scan, after scan, after scan and might miss a one-millimeter change in the brain or something like that, and the AI helps direct that person’s vision to that. That’s where we are currently.” (21:57—23:03)

“A big part of our thinking as dentists, our own thinking towards ourselves, our own profession, as well as how the public views us, is that we have to step away from being tooth carpenters. We are not that. We are not smile makers. Yes, we are, but we’re not just that. We’re not tooth straighteners. We’re doctors, physicians of the oral and maxillofacial complex, and that encompasses an understanding of how those teeth that — of course, the aesthetic component. Dental patients will see that as part of their cosmetic repertoire. But we know better. So, changing that mindset, not just within the general population, but also our medical colleagues who don’t know what we’re doing, who don’t understand the importance of what we’re doing.” (25:08—26:10)

“I speak at medical conferences, head and neck radiology conferences, showing them — because they’re always talking about noses and sinuses and things like that. I come and say, ‘Hey, but did you notice that this person who has that kind of blockage because of their chronic sinusitis also has a face that’s very long, a mouth-breathing phenotype? His jaws are small. He’s not sleeping. The kid has ADHD, etc.’ Putting those pieces together is completely foreign for our medical colleagues. And then there’s us, as dentists, where we need to step up to the plate and understand what a patient’s phenotype means. Read between the lines. There’s stuff they’re not going to be able to articulate, and a big part of that isn’t just the phenotype and the way the patient appears to you at this time point, but also what has happened in their past — not just physically, but also emotionally and psychologically . . . Psychological trauma, PTSD, all that changes the way that you use your jaws. If you’ve ever heard of bruxing, clenching, these people with these huge masseters and temporalis because of all the stress that they’re under, that is your body basically speaking your mind. That is your body translating your emotions into physical form. And if you don’t deal with that, then no matter what you do dentally, no matter how many splints you put in, no matter how you change the occlusion, whatever it is, that’s not going to get fixed if you don’t change what’s in their heads. They’re going to keep breaking all those crowns.” (26:10—28:02)

“This oral maxillofacial radiology thing is a specialty, just like any specialty that we know, orthodontics, perio, or whatever. You have to invest the time and the education to be able to do it effectively. You can’t be going straight to the thing that you want to do. There’s a methodology. There is a sequential methodology to getting the scans read.” (29:46—30:09)

Snippets:

0:00 Introduction.

1:36 Dr. Tamimi’s background.

5:36 Why this is important in dentistry.

7:35 What clinicians get wrong or misunderstand most.

11:23 Bone is alive.

13:57 The future of imaging.

15:46 Don’t be afraid to use imaging when necessary.

19:06 4D, explained.

21:21 AI’s role in 3D imaging.

24:41 Change the perception of dentistry.

28:04 Last thoughts.

30:15 About Dr. Tamimi’s courses.

Dr. Dania Tamimi Bio:

Dr. Dania Tamimi graduated with a dental degree from King Saud University, Riyadh, Saudi Arabia. She trained at Harvard School of Dental Medicine and earned a Doctor of Medical Science (DMSc) and certificate of fellowship in Oral and Maxillofacial Radiology in 2005. She is board certified by the American Board of Oral and Maxillofacial Radiology (ABOMR) and is a Fellow of the Royal College of Physicians and Surgeons (Glasgow).

She is a reviewer and an Editorial Board member for Oral Surgery, Oral Pathology, Oral Medicine, and Oral Radiology (OOOO), as well as a reviewer for DMFR, Oral Radiology, Head and Neck, Angle Orthodontist and AJO-DO. She is the lead author on two textbooks, Specialty Imaging: Dental Implants (which has been translated to Portuguese and Russian), and Specialty Imaging: Temporomandibular Joint and Sleep-Disordered Breathing, and is a co-lead author on Diagnostic Imaging: Oral and Maxillofacial (translated to Spanish). She lectures nationally and internationally.

She currently runs her oral and maxillofacial radiology private practice in Orlando, Florida.