We only diagnose what we know and sometimes we need x-ray vision

It is a universal truth in medicine and other sciences that investigate and interpret signs and symptoms. For us, clinicians, the signs and symptoms that the patient reports are clues that guide our medical, scientific and logical reasoning. They allow us to combine our knowledge accumulated over decades of study, and crystallized by our medical and surgical practice over the years and the long hours of work with our patients.

On the other hand, our society is evolving exponentially. Scientific knowledge is much easier to obtain and distribute today in the world’s knowledge centers. Its speed makes us feel small, slow and limited when we try to keep up with the best and latest in our field of medical intervention.

Every day scientific articles are published on a certain topic in a certain area. These cumulative contributions, smaller or larger, allow science to move forward. They allow us, as doctors, to follow this progress and the symbiotic relationship between doctors and science, where both contribute to mutual success. In the end, patients will be the big winners. And the doctor-patient relationship, which we learn and do everything we can to make it right, balanced, fair, perfect and protected, will be tremendously enriched.

With this enormous technical and scientific evolution, we have added to our daily clinical practice a new “arsenal”, which allows us to be faster to diagnose, to devise more precise treatment plans according to priorities and severity, and also to have safer and more predictable treatments, which are the options we provide to our patients.

And these treatments tend to be more predictable, effective and efficient. Why?

Because:

We have better means of diagnosis
We work daily to improve our training, in the medical, scientific, technical, radiological, computer science fields, etc.
Currently the surgery is inseparable – in my case, oral surgery and implantology – from digital and computer technology, which helps us in surgeries.

This technology intervenes in:

Diagnosis
Planning
Treatment
Post-surgical control and maintenance.

When I have a patient who’s going to have surgery, I start by doing a medical history.

In my opinion, there is no medicine without a medical history.

We, as people, are a product of our stories and our experiences. Likewise, the patient, with his symptoms and the signs that we observe in the attentive examination of the patient, intraoral and extraoral, is also ready to tell his story.

We need to know how to listen to the patient. Listen to and understand the stories, which may have a practical and direct reflection on the pathophysiology of the disease, and differentiate from those that serve to distract us, or even to help the patient himself to remember, and to fit the pieces of his puzzle.

In diagnosis, it is very important to have access to the best and most current diagnostic aids. This is something that good oral surgery and implantology can never give up.

Here, imaging is extremely relevant, in its radiological aspect.

In my clinics, I have at my disposal current, “state of the art” technology, as it is now trendy to say.

1 – Digital periapical x-ray that allows detecting and/or evaluating and measuring:

small lesions in the hard tissues in the region surrounding the tooth
the presence of dental caries
intra and extra-radicular resorptions
Proximal and distal bone defects for each tooth
Distance from relevant anatomical structures, such as nerves and anatomical cavities, which cannot be injured, let alone harmed, as it causes temporary or definitive clinical symptoms and complications
Intra and postoperative placement of dental implants
Inflammatory and infectious bone diseases
Dental trauma

As a limitation, and generally speaking, there is the size of the intraoral probe. Because it enters the oral cavity, it’s small in size. For this reason, the radiological image will also have smaller limits, not allowing us to evaluate more than 1 to 3 teeth and their respective surrounding areas with each radiation.

2- Panoramic x-ray, digital orthopantomography, which is an important diagnostic aid in several situations:

– As the name implies, the panoramic X-ray, called panoramic image, provides the clinician, who requests and studies it, with a general image of the hard tissues, bones and teeth of the oral, nasal and antral cavities (maxillary sinus). For example:

It acts as the first diagnosis and the platform from which a treatment plan is initiated.
Allows, with only one 2D cut (2 dimensions), to visualize all dental pieces in the mouth and their adjacent structures (periodontal ligament and alveolar bone).
Regarding traumas, it is possible to detect a reasonable percentage of dental trauma (the first option is a periapical x-ray), jaw trauma, mandibular and maxillary bone trauma, temporomandibular joint trauma (although it is not the preferred examination for this type of diagnosis)
Granulomatous and cystic lesions in hard tissues
Surgery planning for implant placement

3 – C.B.C.T. – (Cone Beam Computed Tomography), which presents a 3D study of anatomical structures. It appeared to respond to the need for more reliable and accurate information than that given by 2D examination, such as orthopantomography. At the same time, it emits less radiation than a conventional tomography.

This allows:

A more detailed study to plan implant surgeries.
A safer approach during dental extractions close to noble anatomical structures such as nerves
Greater accuracy in measuring the bone dimensions present and available
Virtual planning of the surgeries with the possibility of putting in the image the models of implants, with their qualities and dimensions
3D reconstruction of images, for oral and maxillofacial surgery

In my clinical activity, patient safety always comes first, whether in accident prevention, biological contamination, cross-infection between patients and the medical team, or between patients, and radiological risk assessment and protection.

Everything begins with the clinical history and the collection of information on the patient’s health status, avoiding whenever possible the use of radiation, particularly in pregnant women and children, respecting the specific guidelines of the General Directorate of Health (D.G.S.) and the Order of Dentists (O.M.D.).

Our clinics meet the required requirements, have protective material for patients and staff, radiation meters and strict radiological safety control by the competent authorities, with audits conducted by independent entities created for this function.

As I believe that our patients are increasingly interested and proactive in sharing therapeutic decisions, in the doctor-patient relationship, I also want to add, in this article, a comparison of the radiation between the different radiological examinations.

The latest C.B.C.T. devices and above, like the one we have in our clinic, allow pulsed light to be emitted instead of continuous light. Exemplifying:

– A scanner lasts between 5 and 40 seconds, depending on the type of examination and area to be registered. The larger the area, the longer the exposure time.

– For a 20-second scanner, we can have, by emitting a pulsed light beam, an exposure of only 3.5 seconds to radiation. (Whaites E, 2013)

The effective radiation dose depends on:

Quantity and time of exposure
The size of the field of view (the bigger, the more radiation)
The type of equipment used (modern digital equipment emits less radiation than old analog equipment)
The anatomical location of the field to be irradiated and studied (Whaites E, 2013)

Examples of radiation levels, according to the type of radiological examination:

(effective dose units – (E) mSv)

Periapical radiography – 0.0003 – 0.022
Panoramic radiography – 0.0027 – 0.038
Chest X-ray – 0.014
Skull X-ray – 0.02
Head tomography – 1.4
Abdominal tomography – 5.6
Jaw tomography – 0.25 – 1.4
Dental-alveolar CBCT – 0.01 – 0.67
Craniofacial CBCT – 0.03 – 1.1

(Whaites E, 2013)

As in everything, we have to adapt and select, for each clinical situation, the appropriate diagnostic aid.

There’s no such thing as a perfect exam. That’s why in some situations we have to order and take more than one exam. But today, with the technology at our disposal, we are contributing to an increasingly predictable, effective and safe clinical practice. The possibility of virtually planning our surgical interventions allows me, as a surgeon, to be increasingly safe, confident and happy, supported by a technology that aids our daily work – both in my area of oral surgery and implantology, and in the virtual planning of oral rehabilitation. But I only say what I know. I will let my colleagues talk about their specific areas.

This is the beauty and safety of teamwork. We at the Clínicas CERO don’t give up these elements.

Finally, I would like to thank you for your time and attention to this text.

See you soon and don’t forget to be happy. After all, smiling doesn’t hurt.

If smiling gives you pain, nausea or an imbalance, see your dentist.

See you next time!

Dr. Luis Pinheiro

Master in Science (MSc) in Oral and Maxillofacial Surgery at Eastman Dental Institute – University College of London
Associated Member of the British Association Of Oral Surgery (n.º 2277)
Associated member of the Portuguese Society of Oral Surgery
Private Practice in Oral Surgery and Implantology in Lisbon
Implantology and Advanced Surgery in Corpse – University of Barcelona
Rehabilitation of Atrophic Jaws with Accreditation in Zygomatic Implants – INEPO – São Paulo
Permanent member of the S.I.N. – Implant System – as a speaker for Portugal and Europe, with more than 1000 hours of training given, Oral Surgery and Implantology

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Case of the Month – Nuno Inácio

Dr. Luis Pinheiro May 5, 2020

Nuno Inácio Age- 40 Country – Portugal Description of the Clinical Case The patient arrived at the clinic with his

We only diagnose what we know and sometimes we need x-ray vision

And these treatments tend to be more predictable, effective and efficient. Why?

When I have a patient who’s going to have surgery, I start by doing a medical history.

In my clinics, I have at my disposal current, “state of the art” technology, as it is now trendy to say.

Dr. Luis Pinheiro

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