Do you need cone-beam CT? Part I

Do you need cone-beam CT? Part I

April 29, 2008 -- It began as a scan of the patient's lower jaw in preparation for implants. But what was supposed to be a routine procedure in his Fort Lee, NJ, office turned out to be an event that prosthodontist Scott Ganz, D.M.D., still talks about years later.

First, the patient was amazed that the scan -- conducted with Dr. Ganz's new cone-beam computed tomography (CBCT) scanner -- was over in a matter of seconds. But more important, the scan revealed a huge cyst in the lower jaw that would obviously need to be removed.

Both the patient and the doctor were pleased that Dr. Ganz had invested in the CBCT scanner, which offers detailed 3D images. The cyst may have gone undetected otherwise, and the system allows Dr. Ganz to monitor the patient's ongoing condition.

"We were alarmed at first," Dr. Ganz said. "Luckily, the cyst turned out to be benign. But because there is a danger of recurrence, we have to scan it periodically. The CBCT device lets us do the work quickly and with relatively low dosages of radiation to the patient."

CBCT offers a huge leap forward in dental imaging. For the first time, you can make 3D images in your own office. But any device that carries a price tag of $150,000 to $250,000 needs to be treated as "more than a piece of furniture," in Dr. Ganz's words. In this first of two parts, we examine just exactly what the new technology offers and who should take advantage of it. For anyone planning to do a lot of implants -- and various other specialty procedures -- the investment may pay off quickly. But those dentists more focused on hygiene and routine restorations could wind up paying for razzle dazzle they seldom need.

What is cone-beam CT?

CBCT is a digital x-ray technology used for the head and jaws. It differs from other types of computed tomography (CT) in that multiple diffuse x-ray beams are emitted by the x-ray source. The raw images are then reassembled using a computer algorithm to produce a 3D volumetric image that depicts skeletal, dental, soft tissue, airway, and other internal structures. What's more, it can produce a panoramic scan in as little as 20 seconds.


Yet this new technology hasn't exactly spread like wildfire. In fact, fewer than half of the Kansas dentists who participated in a recent study knew that technology such as cone-beam CT exists. "The most surprising thing," said Anas Athar, D.D.S., an assistant professor of oral radiology at the University of Missouri-Kansas City, "was that, of the 52% who have at least heard about CBCT, few fully understand what it is."

Such ignorance is common because dental schools don't teach enough about the technology, Dr. Ganz. said. And dentists have been reluctant to embrace cone-beam CT because they don't fully appreciate the difference between it and conventional CT. "The problem with regular CT is that you had to send the patient to a radiological center to get the scans," he said. "That required them to go to a huge machine and be exposed to a lot of radiation. Cone-beam CT removes those barriers. You still need education, though. You need to tell students it is a valuable tool."

What cone-beam CT can do for you

Another reason some dentists don't know about cone-beam CT is that it's not for them. If you're a general dentist with few ambitions below the gum line, cone-beam CT could be a waste of your money, said Edwin Parks, D.M.D., M.S., director of dental radiology at the Indiana University School of Dentistry in Indianapolis.

"It's a shotgun when all you need is a fly swatter," Dr. Parks said. "If you have a basic 'drill, fill, and bill' practice, you don't need it." For classic exposures, CBCT may not even work as well traditional intraoral x-rays. The images will be in 3D images but the resolution won't be as sharp as with digital intraoral scanners.

Aside from the big expense (which includes maintenance and possible upgrades to your computer and other equipment), a lot of time may be involved. You and your staff will need training on how to operate the machine, and you may need training on how to interpret the images.

"The single biggest misconception is the time required to learn the new technology," Dr. Ganz said. "A CBCT device is not a turnkey operation. You don't just turn the device on, do a scan, and start reading it. You have to manage the workflow and the flood of information you are going to get."

But if you do more complex procedures -- or want to get into them -- then cone-beam could improve your banker's smile as well as those of your patients. "If you are in a practice that does implant placement, it is pretty good," Dr. Parks said. "When you are taking out wisdom teeth, it gives you a good look at the mandibular canal."

CBCT can also help diagnose and plan treatment in periodontics, prosthodontics, oral surgery, orthodontics, TMJ dysfunction, and complex endodontics.

"It allows me to work with more confidence," said Ronald K. Shelley, D.M.D., a general dentist in Glendale, AZ. "I was doing implants and surgery before the cone-beam, but when I got close to a nerve or had to deal with the sinuses, a lot of cases were excluded [because I didn't have] firm evidence of where I was going. Cone-beam gives you 3D information that is really invaluable."

Software such as SimPlant can be used with cone-beam CT to create virtual stents that enable dentists to position implants with precision.

When investigating endodontic lesions, dentists can adjust the angle of the beam to investigate other roots, auxiliary canals, and possible radicular fractures. "With CBCT, you'll do your scans more accurately, without guessing, and with less morbidity to the patient," Dr. Ganz said.

Some orthodonists say CBCT virtually eliminates the need for conventional orthodontic x-rays.

And some dentists who create appliances for sleep apnea say that cone-beam CT helps them visualize the oral-nasal airways. "You need to know where the bone is in three dimensions so you can place it accurately," Dr. Shelley said.

Cone-beam vs. conventional CT

Of course, conventional CT can do most of these tricks as well. So what are the pros and cons of the two technologies?

Perhaps the biggest advantage of cone-beam CT is that you can keep it in your office. Conventional CT machines are too big and too expensive. And having the machine in your office means keeping the patient in your office. First, you won't risk introducing the patients to another practitioner. Second, you'll save them a trip to another facility. Third, you will impress some patients just because you own the latest technology.

And fourth, you can use the detailed images to make a more convincing case for treatment. "You can sell a case that may amount to $10,000 or $20,000 that could never have been marketed any other way," Dr. Ganz said.

But along with the delights of ownership come the headaches. Aside from the time and money involved in ownership, you'll have to take full responsibility for interpreting the images. According to some experts, that means you could be liable for malpractice if you miss a warning sign -- even for a medical problem such as a calcified carotid artery.

Until you are fully trained in reading the output, you may want to send all your images electronically for interpretation. "The images should be interpreted by an oral and maxillofacial radiologist to make sure the volume is thoroughly examined and properly interpreted," said Gail F. Williamson, R.D.H, M.S., a radiology professor at the Indiana University School of Dentistry.

This undermines some of the advantages to owning the machine in the first place. Count on $75 per interpretation -- which brings us back to the hard question of dollars and cents. Just how many images would you need to justify the big ticket of cone-beam CT? For the answers to these questions, look for Part II of this series, coming next week.

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CDA 2008 Spring Scientific Session preview

CDA 2008 Spring Scientific Session preview

April 29, 2008 -- Have implants taken the place of endodontics? Will changes in the Current Dental Terminology code affect the way you get reimbursed? Do any of the new oral cancer tests really work?

Experts will address dozens of such timely questions starting this Thursday at the California Dental Association (CDA) Spring Scientific Session in Anaheim. The session features four days of lectures; hands-on training on the latest trends, technologies, and techniques; and an exhibition floor with more than 600 participating companies.

The DrBicuspid.com team will be there from day one, covering the hottest sessions with daily reports.

Among the speakers will be L. Stephen Buchanan, D.D.S., who will conduct a hands-on course on the art of endodontics; Paul Feuerstein, D.M.D., who will talk about new products needed for a high-tech practice room; and Karen Davis, R.D.H., who will discuss effective communication and enrollment skills for the dental team.

Among the other hot topics:

Maximizing productivity and practice growth
The traumatized dentition: Diagnosis, prognosis, and treatment
Minimal intervention and maximum interception strategies for dental caries
Quality imaging in dental practice
Crystal methamphetamine: Your teeth, your health, your life
Charting the course (features of proper record keeping)
Rethinking endodontics or how to choose between endodontic treatment and implant therapy
Recognizing cultural differences in the patient population
To keep the approximately 30,000 attendees entertained, an exclusive party will be held at nearby Disneyland. And for the dentist with refined taste buds -- wine seminars!



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New lawsuits follow clinic's $10 million settlement

New lawsuits follow clinic's $10 million settlement

April 29, 2008 -- After settling a multimillion dollar federal case, North Carolina dentists specializing in Medicaid patients now face lawsuits from 13 patients.

One patient, Antavia Digsby, underwent 14 pulpotomies and received 14 stainless steel crowns in a single sitting on May 9, 2003, when she was 5 years old.

Earlier this month, the Medicaid Dental Center (MDC) agreed to pay $10 million to the U.S. government and the state of North Carolina to settle claims that it fraudulently billed Medicaid for dental care performed on impoverished children at its clinics.

Digsby's attorney, Darren Dawson, has filed the suit on her behalf and said that he will soon be filing suits for 12 more patients with similar complaints, including one who had 16 pulpotomies in a single sitting. He said that all the children were between the ages of 4 and 6 years old.

"The children were very young, the work was done without the full consent of the parent, and some were restrained with a papoose board," Dawson said. "It was unauthorized work to overbill Medicaid."

James Wyatt, MDC's attorney, called the allegations "silly" and added that all parents have to give written consent for any procedures at the clinics. "The children not only needed that work, it was imperative. The real question is why did the parents let their children's teeth get in such a horrible condition?"

The dentists named in the lawsuit are MDC owners Michael A. DeRose, D.D.S., and Letitia L. Ballance D.D.S., and Heather Berkheimer, D.M.D., the dentist who performed the procedures. MDC is now operating under the name Smile Starters.

The $10 million settlement was reached after the government alleged that the chain of clinics run by Dr. DeRose and Dr. Ballance submitted reimbursement claims for unnecessary pulpotomies and stainless steel crowns to Medicaid, and failed to obtain informed consent.

But Wyatt denies that the dentists committed fraud. "All of the work was high-quality," Wyatt said. "The disputed billings involved differences of opinion among knowledgeable experts. All procedures were supported by either X-rays or physical examination."

The charges are regarding procedures done from 2001 to 2003 at the chain's clinics in Charlotte, Raleigh, and Winston-Salem. On October 1, 2004, after the government lawsuit was filed, the North Carolina Medicaid program established a reimbursement limit of six stainless steel crowns per appointment.

This limitation does not apply to hospital operating rooms and ambulatory surgical centers.

"There was a concern that child recipients were in the chair too long, and their welfare was the main motivation behind this change," said Mark Casey, dental director for North Carolina Medicaid.

Nine dentists working for Medicaid Dental Center -- John Lyons, Jeffrey Zieziula, Erron Brady, Lori Petree, Christopher Ballinger, Michelle Wilkerson, Nermin Ballinger, Dr. Balance, and Dr. DeRose -- received written reprimands from the North Carolina Board of Dental Examiners in 2005. Dr. Ballance and Dr. DeRose were placed on probation for three years.

"Health care professionals who abuse their positions and engage in excessive treatment regimens and excessive billing practices will not be tolerated," said Gretchen C.F. Shappert, U.S. Attorney for the Western District of North Carolina, in a written statement.

M. Alec Parker, D.M.D, executive director of the North Carolina Dental Society, argues that the issue is not quite black and white.

Medicaid reimbursement rates to dentists are very low, he noted. If dentists treating Medicaid patients want to stay profitable, it pushes them into a different model of service -- one that requires them to do more procedures, he said.

"I worry about painting these Medicaid centers with a broad brush, because that will put a lot of people who are allowing more access to care out of business," Dr. Parker said.

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Build your perfect Web site: Part II

Build your perfect Web site: Part II

April 29, 2008 -- Louis Woolf, D.D.S., thought visitors to his Web site might like a snazzy video introduction to his practice, the Sachem Dental Group, in Suffolk County, N.Y. But after talking to his designers at American Eagle, he changed his mind.

Such introductions may not find their way onto search engines, the consultants said. And if patients can't find your site, there's no point having one.

Surprises like this are common for dentists as they design or upgrade Web sites for their practices. In Part I of this three-part series, we offered advice on planning a Web site and selecting designer. But design is only the beginning of your Web site's journey. In this second part, we'll look at the key issues in hosting and promoting your site, as well as integrating it into your back office.

Hosting

Hosting questions are so important that you should bring them up when interviewing prospective designers. As your practice changes, you may need to change a photo, describe a new service you offer, or provide details about a new office that has opened. So you need to figure out who will do that.

If you've signed up with a service that offers template-driven designs, you may be able to make the changes yourself, by simply filling out a Web form or changing text.

If you don't use template-driven designs, though, things get more difficult, because someone will have to change the actual page itself. It can be exceedingly time-consuming and frustrating, and if you're not a pro, you can do serious damage to your site.

Some design firms will include making changes as part of their overall fee, and won't charge for changes after that.

Also ask prospective designers if they will host your site. Hosting means they store the data that makes up your site on their computer and connect that computer to the internet, essentially giving the site its home on the Web. Larger design firms tend to do their own hosting, while smaller ones are likely to refer you to someone else.

This dental Web site was designed by TNT Dental.
Prices for hosting can vary tremendously. Sesame Dental, for example, will host your site free after they've designed it for you. (A typical design fee runs $4,990, the company says.) But the company charges for various value-added services to dental Web sites, such as integration with practice management systems.

TNT Dental, on the other hand, charges varying hosting rates, depending on the services offered. Prices range from $49 to several hundred dollars a month.

What do you get for your money? Most of all, you want reliability; you don't want your site down for the count when people are looking for it. So check references.

Finding out about how tech support is handled is also a good idea. Is it only via e-mail? That's not much help in an emergency. If telephone support is offered, at what hours is it available? Try calling the tech support number several times to see how easy it is to get through.

Promoting your site

Having a Web site may be good for your ego, but if no one can find it, it won't do any good. If your site will be primarily used for existing patients, this is no problem -- just give them the site's URL.

But if you want to find new patients, they'll need to be able to find it. You'll want your site to appear as high up as possible on the results page when patients search for a dental practice through Google or another search engine.

Cracking the algorithms that search engines use sometimes seems akin to voodoo. After you've stocked up on chicken blood, you can take a few more practical steps. One is to realize that multimedia -- such as fancy video introductions -- won't help, as Dr. Woolf learned.

Another step is to use as much unique content as possible. This is where using precreated content can hurt you. Because other dental sites have the exact same information, search engines won't list your site as high in the rankings.

Finally, come up with a limited list of terms that you would like to appear high up in search results for -- perhaps ten. Make sure that several of those terms are geographical. It will do you no good if someone in Mexico City comes across your Web site, and your practice is in Ames, Iowa. There are more and less sophisticated ways of including those terms in your site's content, which is one reason you may need to consult a professional.

Many firms promise that they will do what is called search engine optimization (SEO). This means making changes to your site's content or layout so that it will appear higher in search engine results, as well as submitting your site to search engines.

Many design firms, including TNT Dental, offer this as part of their design package. Outside firms offer this service as well.

Beware of firms that charge on a pay-per-click model -- in other words, you pay them as much as $20 every time someone clicks to your site. These charges add up fast. But even companies who charge a flat fee typically want at least a hundred dollars a month.

Is it worth the money? The answer depends on your marketing plan. TNT Dental's co-founder, Tim Kelley, points out that if you plan to use radio, TV, and print advertising to drive people to your Web site -- and you don't expect the site itself to draw users on its own -- then you won't necessarily need to hire someone to do search engine optimization.

If you do choose an SEO firm, Kelley says, you should ensure that you get detailed monthly reports, showing you the traffic to your site and where it comes from. Get a report that shows traffic before the firm begins its search engine voodoo, so you can see actual results.

Back office integration

Depending on what practice management software you use, you may be able to hook your Web site to it, to allow patients to change appointments, make payments, and so on.

Because of the technical difficulties, many design firms don't even offer the service. "It's quite complicated, and we don't think there's a payoff yet," Healey says. "We think it's something that is several years off for most practices."

Sesame Dental, on the other hand, says that it is able to connect a Web site to any of 30 practice management systems. Cost of integration is $264 per month.

The bottom line

If all this sounds like a lot of work, that's because it is. But the payoff can be substantial. Resources like the Yellow Pages directory are being read less and less, while the Web has increasingly become the de facto way that people find new services. A Web site will increase your exposure to potential patients, and help keep your existing patients happier.

Dr. Woolf has high hopes for his new Web site, which recently launched.

"I don't have unrealistic expectations about the benefits we'll get," he says, "but I expect that it will be easier for new people to find out about our services, and our patients will be happier with us. They'll be able to find more about our services, about aftercare, about how to get to our offices, and they'll even be able to print out forms and bring them to the office."

"All in all, we expect to be much better off," says Dr. Woolf.

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Clinic pays $10 million in fraud settlement

Clinic pays $10 million in fraud settlement

April 23, 2008 -- Medicaid Dental Center (MDC) of North Carolina will pay $10,050,000 to the United States and North Carolina to settle claims that it fraudulently billed Medicaid for dental care on impoverished children.

The government alleges that the chain of clinics and its owners, including Michael A. DeRose, D.D.S., and Letitia L. Ballance, D.D.S., submitted reimbursement claims for unnecessary pulpotomies and stainless steel crowns, and that it failed to obtain informed consent.

"These dentists subjected their child patients to invasive and sometimes painful procedures, often for the sake of obtaining money from the North Carolina Medicaid program," said Jeffrey S. Bucholtz, acting assistant attorney general for the department's Civil Division, in a press release.

MDC's attorney, James Wyatt told DrBicuspid.com that the billings were not "fraudulent." "The disputed billings involved differences of opinion among knowledgeable experts," he said.

The settlement concerns procedures done between 2001 and 2003. Both Dr. DeRose and Dr. Ballance were disciplined by the North Carolina Board of Dental Examiners in 2005.

"Any question about the types of treatments given by M.D.C. were investigated and resolved in 2003," said Wyatt. "The clinics are now providing high quality service to people other dentists will not even see."

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