Q: What barriers remain to incorporate digital chairside dentistry, and what is needed to remove those barriers for more adoption?
Chad C. Duplantis, DDS; Dennis J. Fasbinder, DDS; and Daniel J. Poticny, DDS
The process of incorporating digital chairside dentistry invokes much thought and is fraught with common misperceptions. The biggest obstacle for a dentist when adopting any technology is the initial investment. When digital dentistry entered the marketplace, the products had an astronomical price tag. Dentists had to produce a fair number of chairside restorations to justify paying for the equipment. For many of these dentists, this led them to overthink the treatment planning process and try restorations that were outside their comfort zones. Many clinicians were also achieving less-than-satisfactory results, as they “became” the laboratory as well as the dentist. Although much has changed, these are the myriad of concerns that we are trying to overcome in present day.
The first is the misperception that digital dentistry is costly. Although this can sometimes be the case, digital dentistry can be extremely affordable. A clinician can easily enter the digital world for a fraction of what it cost 15 years ago. This not only represents a lower cost on the equipment, but it can also represent a positive return on investment (ROI).
The second concern is that for the clinician to practice digital dentistry, the dentist must fabricate all restorations chairside. This is not the case; in fact, the laboratory’s present-day role may represent the largest shift in digital dentistry. Laboratories have adopted extremely useful and efficient digital workflows. They can not only produce restorations digitally, but can also receive digital impressions. In fact, many laboratories would prefer to receive digital impressions because of higher success rates and lower remakes. A dentist has no need to practice dentistry any differently; traditional restorations are available with no disruption to practice workflow.
Another worry is the accuracy of the digital technology and restorations produced. Several citations in literature prove the accuracy of the digital devices. The equipment available today should present no concern whatsoever to the dentist looking to enter digital dentistry.
The final issue creates a crucial dilemma: How does one decide what is best for his or her practice? To begin, the dentist needs to decide what he or she wants from the equipment. In other words, does the clinician want better laboratory-fabricated results, improved chairside results, or both? I would recommend becoming educated on the options. There is certainly no shortage of material on the various digital devices in current literature. In addition, colleagues who are using the equipment are an invaluable source of information. Find out who’s having success and why. Learn about which laboratories they are using and the financial impact digital dentistry has had on their practices. The final piece of the puzzle would be setting a budget. The clinician must consider all factors and discern what the practice is willing to spend. With all the options available today, digital dentistry can be incorporated into any budget.
The first barrier for most doctors to overcome is acceptance, which includes a consideration of the potential quality of care that the technology provides. Such concerns involve restoration adaptation and fit, material strength, esthetic outcome, and clinical longevity of the restoration. This barrier continues to evaporate based on the considerable amount of published evidence of the predictable outcomes and longevity of chairside computer-aided design and computer-aided manufacturing (CAD/CAM) restorations, as well as the large number of clinical case reports demonstrating how to achieve good clinical outcomes. As interest in digital technology continues to grow, doctors will naturally better understand the application, limitations, and success of chairside digital dentistry.
The significant capital investment in the equipment is also reported as one of the more common barriers to integration. This represents a significant change in how dental practices consider their costs for treatment. Material expenses, fabrication expenses, and logistics of transmitting impressions, models, and restorations are generally considered acceptable costs of providing restorative treatment. These prices are often determined by groups outside of the practice, rather than controlled by the practice. The ROI for chairside CAD/CAM technology is based on minimizing these costs and recapturing the time lost with the nonproductive second appointment associated with delayed delivery of restorations after the preparation appointment. This means the financial barriers are more about ensuring an ROI rather than upfront costs. Anything becomes expensive if it is not utilized. As doctors understand how the costs can be controlled and appointment times made consistently more productive, the financial barriers appear less intimidating.
Another significant obstacle has been the relative advantage of implementing chairside digital technology and its ease of use. However, this actually involves more than just learning how to use a system. It also includes implementing it into a busy practice schedule so it becomes a consistent technique employed by the practice. Although it is much easier to learn to use systems these days, doctors still are concerned about seamlessly integrating the chairside digital workflow into their practice schedules. However, some diverse practice environments, including military clinics, corporate dental clinics, insurance-based private practices, and fee-for-service practices, have successfully integrated chairside CAD/CAM technology. This affords more chances for interested doctors to obtain useful information on opportunities and techniques for integrating the technology into their own practices.
Another concern has been identifying which clinical applications are possible with chairside digital systems. Dental practices are as diverse as the practitioners owning them. Chairside CAD/CAM systems have moved beyond merely offering clinicians the ability to fabricate single-tooth restorations. Anterior veneers, simultaneous multiple crowns, implant surgical guides, implant custom abutments and screw-retained crowns, implant provisional abutment and crown restorations, fixed partial dentures, and orthodontic applications are just some of the more recent clinical applications now available in chairside digital systems. As clinicians gain greater awareness of the various applications available for integration, doctors will consider which applications and systems are optimal for their practices.
Perceptions remain that digital chairside dental restorations are not the equal of a laboratory product in terms of performance and eye appeal. Evidence and anecdotal perspectives indicate otherwise. Quality is a function of the desire and ability of the operator to reach the same; a clinician chooses what to deliver as acceptable treatment no matter who produces it. New skill sets are required for digital chairside dentistry. However, these skill sets are easily learned if training is made available. Manufacturers and distributors should supply training with all systems at a level sufficient to achieve and maintain competency. Dentists would do well to examine the evidence.
Laboratory fees are dropping and are predicted to continue dropping because “commoditization” for indirect dental restorations has occurred through widespread adoption of digital technologies by laboratories. Standalone intraoral scanners are widely available at accessible price points, allowing dentists to complete the “digital circle” with a digitally enabled laboratory and enjoy even lower laboratory fees. While not a direct “barrier,” it is a now viable competitor to the notion that all dentists will adopt digital chairside dentistry systems.
Costs for digital chairside dentistry (among the most expensive) have not decreased over time like other technologies. However, no other dental technology has a greater potential to lower operational costs. Dentists are encouraged to review their budgets with their financial consultants. While most digital chairside system purveyors have good financial estimators, they won’t know the dentist’s full financial picture. Dentists should seek sound, impartial advice.
Integration with other digital technologies is still lacking and inconsistent between platforms. Dentists do not need more things that cloud services, better hardware design, and digital consolidation could accomplish. This would certainly validate current and even higher price points by reducing digital “redundancy,” which is growing in dentistry. Huge opportunities exist for cross-platforming in terms of diagnostics, patient education, the digital dental record, education, and prevention, to name a few. Multifunction cameras, greater mobility, plug-and-play equipment, and virtual patient records with front-to-back integration are innovations that are not so farfetched for dentistry. In other words, digital chairside dentistry should be “more than a restoration.”
Digital chairside dentistry is unevenly championed and taught in dental education, and this must change. The future has arrived sooner than schools’ abilities to educate. Politics, funding, and allocation of resources play a part, and while progress is being made, it needs to happen quicker. Students today expect to practice digitally tomorrow and because the future for “digital process” is known, it is incumbent on administrators and faculty to move the needle. Virtual reality is used to train and educate numerous professions; are future dentists less deserving? Reassessment, prioritization, and commitment are in order, and hopefully sooner rather than later.
Dentistry is a service, and successful businesses reframe and adapt. The message of one-visit dentistry needs amplification because that’s what patients prefer.
About The Authors
Chad C. Duplantis, DDS
Fort Worth, Texas
Dennis J. Fasbinder, DDS
University of Michigan
School of Dentistry
Ann Arbor, Michigan
Daniel J. Poticny, DDS
Adjunct Clinical Associate Professor
University of Michigan
School of Dentistry
Ann Arbor, Michigan
Grand Prairie, Texas