President’s Message
November 2007
1. The next NCAO meeting – to be held at the Sheraton Imperial in the Research Triangle Park in February 2008– is going to be a good one. The featured speaker at the February 2008 meeting is Dr. Richard P. McLaughlin from San Diego, California. I first heard Dr.McLaughlin at a 3M Unitek seminar in Las Vegas about 7 years ago. He had published his first book and his MBT system and prescription had just been introduced to the orthodontic community. His presentation was a revelation for me. Since then, I’ve heard all of his lecture topics, and I think he is one of the best clinicians on the“circuit” today. His recent textbook, Systemized Orthodontic Treatment Mechanics,is a must for the orthodontic library. He is going to speak on the treatment of Class II malocclusions on Friday and follow up on Saturday with a presentation on treatment of Class III malocclusions.
The 2008 meeting will be sponsored in part by 3M Unitek and Dolphin Imaging and Management Solutions. These corporate partners of orthodontics are helping defray the costs of our continuing education by providing financial support for the annual meeting. These particular sponsors were picked because Dr. McLaughlin utilizes their products in his practice and presentation. In return for their financial support, the sponsors will be allowed to set up display booths during our meeting. This sponsorship arrangement will be a first for the NCAO annual meeting. I hope corporate sponsorship will be accepted by our membership and continued into the future.
Dr. Richard McLaughlin
2. Dr. Madeline Serrano – our Past-President – needs our support and prayers. Madeline recently sold and transitioned her practice to Dr. J. Dempsey Smith. Madeline is suffering from an auto-immune illness that has weakened her physically and required her to leave the practice of orthodontics and seek specialty medical care. After working with Maddy the last several years on the NCAO Board, we have become good friends. I feel for her and her family and realize that all of us are only a step away from the same scenario. Please call or write Maddy – let her know we love her and hope she regains her health. To all the young professionals in our organization: buy a reliable and reputable professional disability insurance policy, and set up or get into a practice coverage group as soon as possible.
3. CBCT (Cone Beam Computerized Tomography) - In the Spring 2007 edition of The Dental Forum – the publication of the N.C. State Board of Dental Examiners, the Board published an article on Cone Beam Imaging. (http://www.ncdentalboard.org/pdf/spring07newsltr.pdf)In this article, it is stated that the Board “ views the use of CBCT under the rules applicable to radiographs. Therefore, if you acquire a volume of data,you should be able to interpret the data for a complete and accurate diagnosis. If you are unfamiliar with the full potential of this emerging technology, you should consider consulting with a Board certified oral and maxillofacial radiologist.”
Secondly,the Board stated “having a financial interest in an imaging center separate from your dental office creates the risk of violating the N.C.law against self referral. (N.C. Gen Statute 90-406).
This article almost immediately generated a number of requests to me for either clarification (what does the Board mean?)or for a statement on the position of the NCAO regarding CBCT. The primary question from our members to me was regarding the “volume of data” statement. A CBCT scan obviously generates a large amount of data and as of this date, there are very few continuing education courses available for our members to avail themselves of – and if we cannot interpret the data – we may be liable for missing something. (The Board is very clear on this.) And, if one of our members pools his resources with several other dentists to buy a machine, sets up a radiographic service separate from his practice (ostensibly for tax purposes), and then makes images on his own patients, will he be liable as “self referrer”?
Regarding the “volume of data” statement, I would strongly suggest that before ordering this technology for your patients, you should either be able to read and interpret the data or have a specialist do it for you by prescription – exactly as the Board recommends. The wrong approach is to order a scan and try to interpret it yourself without adequate training – or to make a scan on a patient and have the patient sign a form releasing you from liability for not reading the scan in its entirety. I have spoken to several members who have attended CE courses on CBCT and they have realized that although the amount of data can be intimidating, it is not impossible to determine what is normal from what is not normal.
In his editorial “Befriend your oral and maxillofacial radiologist” in the June 2007 edition of the AJO-DO, Dr. David Turpin recommends the same course of action. He suggests that we should become “cone-beam fluent” by attending courses, or we should refer the images to radiologists for interpretation.
I attended the CBCT course offered September 21, 2007 at the UNC School of Dentistry. The course was a comprehensive review of CBCT imaging: history, technique, dosages, CBCT anatomy, and interpretation. The instructors: Drs. Ludlow, Tyndall, and Platin were very careful to cover the entire scope of CBCT as well as the limitations of the technology. Following the presentations, it is perfectly clear to me that CBCT this will replace the current digital panoramic imaging as our gold standard within five years. The radiation generated by the cone beam scan is a bit higher than our conventional panoramic/cephalometric combination, but that will likely decrease as the technology improves. The price of this technology should decrease in the future as the winnowing process occurs across the industry.
As for generating a consent document to explain away the liability for pathology that may or may not be detected, I think it is a better plan to go to the Continuing Education courses that are available and learn to interpret the data. In fact, one insurance company – Fortress –has already ruled that it will not insure dentists who attempt to have the patient sign such a release. As a NC Board of Dental Examiners member told me recently –“you can’t have the patient consent to negligence”. At the worst, if something is present in a scan that is not familiar or subject to misinterpretation, the images can be referred to UNC or a private service for evaluation and interpretation.
Dr. Don Tyndall - a Radiologist at the UNC School of Dentistry - is fairly confident that in a few years (if not sooner), almost all dentists will be quite capable of interpreting CBCT scans. Freshman dental students are receiving instruction in cone beam anatomy already. Dr. Tyndall and his colleagues at the UNC course are in agreement with the Board in that it is incumbent upon the provider to get up to speed on interpretation as quickly as possible or get a third party (Board Certified Oral and Maxillofacial Surgeon or Radiologist) to do the interpretation and reporting for them. UNC will offer another course in the Spring of 2008 on CBCT interpretation and by then there should be several courses offered around the country. We should all be “cone-beam fluent” in the next few years. This technology is coming very quickly and it should be mastered by orthodontists prior to offering it to our patients..
As for the “self-referral”question – I think we all realize (and this probably includes the Board of Dental Examiners) that this CBCT imaging is expensive new technology that is not yet conveniently available to all orthodontic practices and patients. Private services are available but certainly are not on every street corner yet. So the orthodontist, or group of dentists, who purchase a machine, are naturally going to use it on their own patients – because there obviously is not an affordable, convenient referral alternative for their own patients. It seems reasonable that unless there is an obvious pattern of over- prescription for CBCT imaging on the part of the orthodontist/owner– indicating some sort of profit motive (rather than a true necessity for a 3D image) –that self-referral is almost a necessity in order to proved patients with this technology – at least until market economics (which I think will cause the price of the machines to decrease) provides referral alternatives.
In summary, if you are contemplating purchasing a CBCT machine, you have the following alternatives in determining how to handle the volume of data you will generate:
1. Go to CE courses and learn to interpret the data. Read the data yourself once you are competent and refer to a third party only the cases where there is some question. With the appropriate software,you can construct your conventional cephalometric views from the CBCT images (talk to the Dolphin reps at our next meeting!).
2. Make the images yourself but send your imaging raw data to a Radiologist. Have the radiologist read your data and prepare a report. This can be done by a private service like Carolina Oral and Maxillofacial Imaging or the UNC School of Dentistry. Along with his interpretation, the radiologist can return your data on a disc so you can see it for yourself if you have the appropriate software.
3. Buy a machine and lease it to Carolina OMF Radiology. Carolina OMF Radiology will perform the imaging and interpretation for you as a business partner. Dr. Bruce Howerton will be happy to talk to anyone about this arrangement. Call him at 919-534-7000.
4. Medicaid – Dr. Mark Casey, the Dental Director of the NC Division of Medical Assistance (Medicaid) contacted me in June about seeking the assistance of the NCAO in “helping the DMA Dental Program match deserving recipients with Medicaid enrolled orthodontic providers.” Dr. Casey also asked me to convey his desire to offer his services to any NCAO member who wishes to participate in the Medicaid program. Dr. Casey can be reached at 919-855-4100 if any member wishes to talk to him about enrolling in the Medicaid program.
Dr. Casey also asked me to consider helping the DMA Dental Program revise the current Orthodontic Clinical Services Policy. On behalf of the NCAO, I responded positively to Dr. Casey’s request and immediately called the very capable Dr. David Hall for assistance. Dr. Hall and I met with Dr. Casey and were given an overview of the entire Dental program including provider enrollment, patient record submission for approval, patient appeal processes, and reimbursement rates. This same information can be found online at www.ncdhhs.gov/dma/dental/2ortho.pdf.
Dr. Hall, Dr. John Christensen, and Dr. Tom Griffin and I met in November to discuss the orthodontic Medicaid policy. At the NCAO meeting in February 2008, I will officially appoint Dr. Hall to chair a committee to research the relationship between Medicaid orthodontic treatment in North Carolina and the NCAO. Anyone who wants to participate should call me or David Hall. If the Medicaid system can be improved to the point that it is easier to identify and treat the truly qualified patients and collect the reimbursement in a timely and more efficient way, many more of our members might enlist as providers. This is what David and I and Dr. Casey would like to see accomplished. We solicit your input.
Rick Alston
