WEBINAR ON:

3D RADIOGRAPHIC EVALUATION
OF THE PATIENT

SPEAKER: DR. DANIA TAMIMI

This webinar aired live on November 20, 2019, but you can still view the recording.

In this webinar, you’ll learn about

  • Radiographically evaluating the patient as a whole organism with multiple interacting systems
  • Looking for clues in the patient’s morphology that tip you off to the presence of an underlying physiologic condition or disease

Register

SPEAKER

Dania Tamimi

Dr. Dania Tamimi

BDS, DMSc

Dr. Tamimi earned her dental degree from King Saud University, Riyadh, Saudi Arabia in 1999. She trained at Harvard University and earned a doctorate 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). Dr. Tamimi is a co-author on “Diagnostic Imaging, Oral and Maxillofacial”, the lead author on “Specialty Imaging: Dental Implants”, and “Specialty Imaging: Temporomandibular joint”.

Webinar Q&As...

Some of the interesting questions asked during the webinar and their answers:
 

1. I've heard of nasal cycling where the soft tissues of one side of the turbinates swell and then diminish. Does this occur?

The nasal cycle is a normal physiologic process that the nose goes through every 2-6 hours. The turbinates on one side enlarge, then diminish in size and the other side enlarges to allow for the functions of the nose of filtration, humidification and temperature control to occur.

2. How do you evaluate or determine if the turbinates are enlarged or hypertrophied vs the nasal airway?

I look for general signs of rhinosinusitis, such as bilaterally boggy turbinates with very small air passages, mucus pooling and drainage problems with the sinuses due to obstruction of the drainage pathways of the sinus.

3. In a pano view, what landmarks do you use to measure condylar length, when using the measurement tool?

I demonstrated this at the end of the live session please see the recording.

4. What is the best way to electronically send raw DICOM files from one provider to another?

Through the BeamReaders HIPAA compliant portal!  BeamReaders provides this networking service for you to communicate between your team members and referrals as well as with the radiologist.  Our Case Share ability is built into all of our services or can be used stand alone.

5. What are the measurements for open, slightly narrow, very narrow, etc of airway volume?

I think this question is asking what constitutes a small airway. Generally, if I find an airway that has a minimum diameter of around 50mm2 or less, I would consider the patient to be at high risk for SDB. If the measurement is 50-120mm2, then there in increased risk, but all these numbers mean nothing without clinical correlation.

6. When we send a cone beam from another software - Galileos, do you import the DICOM file into Anatomage?

DICOM is a type of file that can be read by any DICOM viewer. DICOM files can be read by Anatomage regardless of the machine the scan was acquired on.

7. What do you teach in your classes? it's difficult with different software that has different features than Anatomage

Depends on the class. It is mainly diagnostics: how to diagnose your patient radiographically. If you come to my TMJ/Airway classes, the focus will be diagnosis of those structures, my implant classes focus on diagnosing the alveolar process and the patient they reside in, my craniofacial pain classes cover dental, sinus, cervical and skull base sources of pain in addition to TMJ and airway.

8. Anymore webinars upcoming?

Nothing planned at the moment, but stay tuned and keep checking the BeamReaders website.

9. Ways to reduce artifacts?

There are some great videos on the BeamReaders website under the education tab that show how to improve your scan quality.

10. Can we measure periodontal thickness?

On a very high resolution scan, this can be done with more confidence than on the lower resolution scans. If this is the purpose of your imaging, use a small field of view and a very small voxel size.

11. Is the software you use available for purchase?

The software is called InVivo. You can find it at Anatomage.com.

12. What are the airway dimensions norms for kids?

The value of the CBCT analysis is not in the numbers. It is in the detection of anatomic and pathologic predisposing factors that put the patient at risk for sleep-disordered breathing. You can measure, but don’t put too much weight on this. I don’t think that there has been reliable research as far as I know that gives the measurements in relation to a child’s age. This meta analysis showed a wide variation in what the researchers found to constitute "Normal". Dave MH, Kemper M, Schmidt AR, Both CP, Weiss M. Pediatric airway dimensions – A summary and presentation of existing data. PaediatrAnaesth.2019 Aug;29(8):782-789. doi: 10.1111/pan.13665. Epub 2019 Jun 19. PubMedPMID:31087466., This one is more for Anesthesia purposes and measures the subglottic upper respiratory tract: Wani TM, Bissonnette B, Rafiq Malik M, Hayes D Jr, Ramesh AS, Al Sohaibani M, Tobias JD. Age-based analysis of pediatric upper airway dimensions using computed tomography imaging. PediatrPulmonol. 2016 Mar;51(3):267-71. doi: 10.1002/ppul.23232. Epub 2015 Jun 17. PubMed PMID: 26083203.

13. Planmeca low dose images- are they clear enough to eval pathology and everything you went through?

I cannot judge the diagnostic value of these images without seeing them, but in general, the lower the dose, the lower the resolution. Some diagnostic tasks require higher resolution than others.  See the BeamReaders video by Craig Dial on Voxels and Maximizing Your CBCT Image Quality for some rules of thumb on feature detection verse voxel size. 

14. How far down the cervical spine does a typical CBCT cover?

C3-C4 in typical 16cm field of view. Can go down to C6-C7 In larger fields of view

15. Hello, could you please very quickly overview/summarize/recap what are the key anatomical areas you eval in each view (axial, sagittal, coronal)

There are way too many anatomical structures for me to be able to type them here. There are some great books that offer this information, such as “Diagnostic Imaging: Oral and Maxillofacial” by Koenig et al.

16. How accurate is the sagittal view in determining the size of the adenoids? I have seen what I thought were large adenoids and referred patients to an ENT and was told that the adenoids were fine.

Look at the soft tissue fullness in the posterior aspect of the nasopharynx in context. Adenoids reach peak age at 6 -12, then diminish sharply at age 16. The ENT may be looking at this in this context in terms of appropriate size for age and not many of them are in tune with our concerns for sleep-disordered breathing. You may be the one that has to educate them.

17. What is the best way to provide you with patient hx?

When submitting a scan through BeamReaders we have a simple workflow that allows you tell us about your clinical observations and concerns.  You can also upload additional images, PDFs, etc alongside the DICOM in the image upload portion of the new case submission process.

18. How many mm transverse is the normal range?

According to McNamara, a maxillary arch with a transpalatal width of 36-39 mm is considered to be adequate for dentition of average size without crowding or spacing whereas maxillary arches <31 mm in width may be crowded and need orthopedic or surgically assisted expansion. Personally, I evaluate not only the transverse dimension of the maxilla but also the nasal cavity and the mandible. I’m looking at these structures as a continuum that may lead to upper airway resistance or crowding of the tongue out of the oral cavity and into the oropharynx.

19. Do you offer an online review. I have one patient that I see some asymmetrical feature on her lower jaw bone that I would like you to check?

You can certainly send the scan through the HIPAA compliant BeamReaders website for one of our radiologists to analyze. Remember that the asymmetry may be coming from another structure and the scan would need to be fully evaluated to rule this out.

20. Do you see volume degradation when you use a DICOM viewer rather that the original software?

I don’t see why this would occur if the DICOM was saved with a lossless compression. Personally, I only use Anatomage and it has been reliable.

21. Do you see significant differences in image quality using different CBCT units?

Yes, some machines do provide better images, but more important than that is the fact that a skilled operator who understands the technology and is well-educated can get more good images from any CBCT machine than an unskilled one.

22. If we see the misalignment of the vertebrae, where should we refer the patient to?

First rule out that the misalignment isn’t due to patient positioning in the machine. You do that by doing a postural analysis, which many dentists do. If you determine an malalignment is present, a physical therapist, osteopath or chiropractor can work with a craniofacial pain dentist or a high level orthodontist who understands the role of the spine in the dentofacial orthopedics to determine the symptoms associated with this and realign the spine.

23. If we see atherosclerosis in the carotid on a regular pano, should we warn the patient to see their physician? Do we send the pano to the physician? The literature hasn't shown such correlation between carotid calcification and stroke.

A carotid calcification is a quiescent end-stage atherosclerotic plaque. It is an indication of the presence cardiovascular disease, but it doesn’t mean that it will actively throw off a thrombus (in fact it is less likely to do so than a non-calcified plaque). Remember that the calcification is the only part of the plaque that is visualized and there may be more stenosis than what you see on the pano. It is good practice to tell the patient what they have and to tell them to talk to the primary care physician or cardiologist if they have not been diagnosed with cardiovascular disease.

24. When a patient is scanned for a TMJ closed, what instructions should be given to the patient regarding their bite during the scan?

Teeth in maximum intercuspation in the closed position. This is vital for evaluation of condylar position in relation to MIP.

25. What is your viewpoint on instructing patient re: Tongue Positioning for Airway/Sleep scans?

As you know, the tongue position on the scan affects the airway dimensions. I have my reservations on how significant these measurements actually are, but if you want to compare apples to apples (dimensions before and after treatment), then both the neck posture and tongue posture should constant on both scans. In order to achieve that, I would say tell the patient to put the tongue up against the hard palate. This, of course, does not represent tongue posture in the supine position and unconscious state, but at least the position is constant between the two scans.  See our video on Sleep Scan Protocols at the bottom of the Sleep Solutions page.

26. Great job thank you - please explain the problem with trying to place patient in an unbalanced occlusal guard - I see this quite a bit, especially if the joint is not stable and adapted

I think this is more of a clinical question and I’d like to know more about the clinical presentation and symptoms. If you’d like to discuss this a bit more, please email me and let’s talk.

27. Can I view with Anotamage the disc of TMJ?

No. It isn't a factor of the viewing software, but the scan type.  CBCT is very poor for characterizing soft tissues.

28. Can you utilize the CBCT for to do cephalometrics?

Yes. You can create your Ceph reformats and do the analyses you would like with software such as Dolphin.  BeamReaders also provides an Image Portfolio service where our team of dental technicians capture all the key images and provide you the Ceph tracing of your choice. 

29. When closing the file it asks if you want to save a copy. Is this copy the full size of the original?

If you choose a lossless compression, yes.

30. Any recommended or better software for image viewing?

Every person has their preference. I prefer Anatomage. Some of my colleagues swear by 3D OnDemand.

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