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We are often asked for the applicable CDT codes for Cone Beam and Panoramic Radiographs, so we wanted to share a resources that summarizes these codes for the most commonly used extraoral exams.  Current Dental Terminology (CDT) codes are alphanumeric codes used to document dental procedures and report them to dental payers. The American Dental Association (ADA) developed and maintains the CDT codes as a standardized language to help dentists and other healthcare professionals communicate You can also download the resource by clicking on the image.

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An interesting topic came up in an online dental forum around what to do when the dental professional notices an indication on a panoramic radiograph that resembles calcification in the carotid artery. 

Based on this, we wanted to provide a few resources that may be useful for dental staff to be aware of this indication along with potential implications.

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Carotid artery calcifications (CAC) are hard, calcified deposits that form in the carotid arteries, which are the major blood vessels in the neck. There are two carotid arteries, one on each side of the neck: the right and left common carotid arteries. Each common carotid artery branches into the internal carotid artery, which supplies blood to the brain, and the external carotid artery, which supplies blood to the face and neck.

These calcifications can indicate a higher risk of cardiovascular diseases like stroke and heart attack. Detecting these early can be vital for preventing serious health issues.

Dental panoramic radiographs can also show the carotid arteries. When dentists review these radiographs, they might notice radiopaque nodular lesions, which can indicate CAC. According to Friedlander et al. [1], these lesions appear separate from the hyoid bone and are adjacent to the cervical vertebrae, usually between the C3 and C4 vertebrae or below. This is close to the location where the carotid artery bifurcates.

Research Findings

Studies such as Magnus Bladh et. al [2]  have shown a strong correlation between the presence of CAC on panoramic radiographs and more advanced carotid atherosclerosis detected by ultrasound (US). Ultrasound is a well-established method for detecting soft tissue changes and plaques in the arteries, which are significant markers for cardiovascular disease. The findings suggest that if CAC is detected on a panoramic radiograph, there is a high probability that more severe atherosclerotic changes will be found upon further examination with ultrasound.

Here are a few sample radiographs from this study:

Understanding the panoramic x-ray projection

Because all panoramic radiographs are projections, it’s important to be aware that the farther from the focal trough the anatomy is, the more distorted it may appear.  In this situation, distortion is not as important because it’s more a matter of flagging the indication.  However, if you are using a panoramic x-ray machine that has the ability to capture multiple focal troughs, then it is possible to gather additional views from the single scan.  In other words, these panoramic x-ray machines allow the operator to extract more information from the scan by evaluating focal planes that may not be as ideal for the dentition, but more ideal to view the carotid artery.

Advantages and Limitations

The ability to detect CAC on panoramic radiographs can be particularly useful in both general and specialized dentistry. Dentists who identify these calcifications can recommend that patients seek medical care for further evaluation and preventive treatment. This can help reduce the risk of CVD-related issues.

However, it’s important to note that not all carotid plaques are calcified, and sometimes the plaques may be located outside the area captured by the X-ray. Therefore, a negative finding on a panoramic radiograph does not necessarily mean that the patient has no vascular issues.

Despite some limitations, the high specificity of CAC detected on panoramic radiographs, coupled with their correlation to ultrasound findings, underscores their importance. While ultrasound can visualize the soft tissue components of plaques that X-rays cannot, panoramic X-rays excel at detecting even small calcifications [2].

In some cases, calcifications may not be visible on panoramic radiographs if they are situated below the imaging area. Yet, when CACs are detected, particularly when they are bilateral and outline the vessel, it strongly suggests significant vascular changes that require medical attention [2].

Conclusion

In summary, panoramic radiographs are a valuable tool in dental practice not only for assessing dental health but also for identifying potential cardiovascular risks. Dentists who recognize CACs on these radiographs can play a crucial role in early detection and prevention of cardiovascular disease. By recommending further medical evaluation for patients with detected CACs, dentists can contribute to improved cardiovascular health outcomes.

While panoramic X-rays should not replace traditional cardiovascular screenings, they offer an additional layer of detection that can be lifesaving. For patients, this means that routine dental exams could also provide important insights into their overall health, highlighting the interconnected nature of dental and medical care.

1.  AH Friedlander, NR Garrett, EE Chin, JD. Baker; Ultrasonographic confirmation of carotid artery atheromas diagnosed via panoramic radiography; J Am Dent Assoc, 136 (2005), pp. 635-640
2.  Magnus Bladh, DDS,a Nils Gustafsson, DDS, PhD, et.al; Defined shapes of carotid artery calcifications on panoramic radiographs correlate with specific signs of cardiovascular disease on ultrasound examination; Oral Surgery, Oral Medicine, Oral Pathology and Oral Radiology Volume 137, Issue 4, April 2024, Pages 408-420

One of the biggest challenges that dentists and dental organizations face is staff turnover. This has been especially acute during the upheaval in a post-COVID inflationary world.  Having great staff is paramount in operating an efficient practice that provides superior patient care.  However, overpaying for staff can mean other parts of the practice get short changed.

To the help the dental practice solve this problem of optimizing, the most powerful tool is data.  However, overly broad and general information isn’t really all that helpful – because every economy is local. 

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Given this, ImageWorks has done an in-depth analysis based the latest dental employee wage data from the Bureau of Labor and Statistics.  This data was released in April of 2024.

The report below includes data on median and upper percentile wage data for dental hygienists and dental assistants across over 500 regions in the US.  This data is useful to help dentists and practice owners audit of their own employment incentives because you can find data specific to your region.

Based on BLS data, you can see how he rate of inflation affected the national median wage for dental assistants and hygienists.  While assistants saw a more dramatic change year over year, it is starting to normalize.  However, hygienists have seen steadier growth that has persisted into the most recent year recorded. 

Download the in depth regional report below to see how your employees compare in your region.

Download Hygienist and Dental Assistant Regional Wage Report

As dental offices grow, restructure, and acquire new offices, ownership is commonly in a situation where they need to move assets and equipment from one location to another.  For many dental offices, the most valuable piece of equipment is their dental cone beam ct system

As a result, many dental offices are interested in physically moving that dental cone beam system to a different location from where it was installed.  However, moving this kind of equipment can be tricky not only because it is a valuable asset, but also because there are a number of issues that can cause problems with the equipment after move.  Ironically, most of these items are very easily avoided if the owner or the mover is aware of them.

Recalibration or realignment may be needed

All dental cone beam systems have a rotating chassis that has a sensor on one side and an x-ray source on the other.  In order to take high resolution images, these two pieces have to be precisely aligned with each other and with the patient positioning mechanism of the machine. 

If the rotational assembly is detached from the main column of the unit, this will typically offset the alignment of the unit such that the unit will need to be realigned in the new location.  Moving the unit without any disassembly may still require recalibration or realignment in the new location as abnormal vibration or movement of the components may also cause the unit to fall out of alignment.

Internal components may break

A dental cone beam machine is not typically designed to be transported in its fully-assembled configuration.  While a good partner performing the move will support and protect the equipment to avoid obvious damage, it’s worth noting that sometimes damage to internal components can be done during the move that may not be outwardly obvious. 

One common area of vulnerability for many units is inside the c-arm assembly.  For example, many dental cone beams have highly sensitive gears, motors, sensors, and potentiometers that are not designed to withstand undue force or stress that may come from vibration or fast movement that may come with rough transport. Furthermore, failure of these mechanisms may not be obvious when the unit is installed in the new location.

To reduce this risk, most experienced technicians will fully bind the unit up (e.g. with shrink wrap) before it is moved.  However, in addition, be aware of how the assembly may move when it rests in different positions.  For instance, even though the unit is fully shrink wrapped in its upright position, there may be unexpected degrees of freedom when the unit is laid on it’s back. Gently push and pull on different areas of the c-arm when it is in its “transport position” to assure there’s no ability to shift or move during transport.

Changes to approved shielding study

If your office is located in a state (or locality) that requires shielding plan approval, then moving the unit to a new location (or even a different position in an existing office) may mean that the original shielding study is no longer valid. 

Some common characteristics that shielding studies take into account are not only the obvious things like the material of the walls and the layout of the room, but also what activity is occurring adjacent to the unit – not only on the other side of the wall, but also above and below. 

If the assumptions of the initial review are not the same, it’s possible that an inspector will identify that the shielding study is no longer valid.

Conclusion

If you are planning a move for your dental cone beam, simply planning for these items will often reduce the probability of any surprises when you look to go live in your new location

Learn more about the Mielscope microscope from ImageWorks

Learn more about the Mielscope microscope from ImageWorks

If my X-rays are coming out too light or too dark, what can I tell my staff to do differently?

As much as traditional intraoral radiography has become a rudimentary part of the office standard operating procedure, it can be easy to forget that there are a ton of variables that can affect the diagnostic value of that PA or bitewing.

While we have found that different doctors have slightly different preferences when it comes to how they like to see their intraoral radiographs, one common question we get is very simply a preference to make the image lighter or darker. 

Sometimes, when the staff member asks about “brightness”, they may actually be referring to “contrast”, which is slightly different.  However, for this discussion, we will focus on simple brightness and darkness.

Understanding the Variables

If the staff understands the variables that cause the radiographs to be light or dark, it can empower them to make their own adjustments so as to provide the exact diagnostic information that the doctor is looking for.

To do this, it’s critical that your staff understand a fundamental correlation:

A dental radiograph that is too dark generally means that it was overexposed (i.e. too much radiation hitting the sensor).  A dental radiograph that is too light generally means that it was underexposed (i.e. too little radiation hitting the sensor).

The variables that can cause an underexposed or overexposed radiograph span from the size of the patient, the characteristics of the anatomy being captured (e.g. anterior vs posterior), the x-ray parameters and the technique.  Of course, this also assumes the equipment is functioning properly.

The obvious question then becomes: what adjustments can the staff make? 

Refining Technique

Technique is typically the first area to check if there has been a sudden change in the lightness or darkness of the radiograph (or if this seems to vary based on the operator).  For instance, lighter radiographs could be a result of the x-ray source being positioned slightly farther from the sensor.  Distance can have a large impact in the amount of radiation hitting the sensor, so positioning the x-ray source slightly farther from the patient’s cheek can result in a lighter radiograph. 

Keeping consistent distance can be an even bigger variable if a handheld x-ray sources is used because this device is held “free-hand” [see article about overlooked challenges of handheld].

Adjusting Parameters

If the technique is not the driver, then the operator can look to adjust the parameters of the x-ray sources.  The key parameters of most dental x-rays include the kvp (voltage), the mA (current) and the exposure time.  Increasing any of these will typically result in a darker radiograph.  On most dental x-rays, the parameter that is the easiest to adjust is the exposure time (typically in milliseconds).  Increasing the exposure time will typically result in a darker image.

So, therefore, one easy approach is:  if a darker radiograph is desired,  the staff can increase the exposure time setting on the x-ray.  If a lighter radiograph is desired, the staff can decrease the time setting on the x-ray.

Of course, this also assumes the staff is operating x-ray equipment within their specified ranges, and practicing ALARA principles.

Adjusting Filters

As with any digital imaging, software filters can also serve to adjust lightness and darkness.  Some common filters that will affect lightness and darkness include:  contrast, gamma, or brightness. 

It’s also worth noting that some software will auto-adjust the brightness.  Sometimes, if the sensor is significantly underexposed for any of the reasons mentioned above, instead of resulting in a light image, it may result in increased graininess.  This is due to the software trying to improve the image, when there is less information for the software to work with (due to lack of adequate radiation). It’s a little bit like zooming in on a low resolution image.

Conclusion

Achieving optimal lightness or darkness in dental x-rays requires a comprehensive approach that considers various factors, including technique and equipment settings. By educating the staff on some of these variables it can empower them to be involved in optimizing the images and “course correcting” when problems arise.