July 2013, Volume 9, Issue 7
Published by AEGIS Communications
-Scott D. Benjamin, DDS
-Joel Berg, DDS
-Daniel J. Coluzzi, DDS, FACD
-Lyndon Cooper, DDS, PhD
-Allen G. Farman, BDS, PhD, MBA, Dsc
-Dennis J. Fasbinder, DDS
-Roger P. Levin, DDS
Experimental microscopic devices search for disease
Caries is still a big problem. Part of the issue is that we don’t see the disease early enough to deal with it medically. Restorative dentistry is needed in most cases given the late stage of detection. This is where new and emerging technologies could have a big impact.
It is useful to examine caries in very young children to understand where we are and what is needed in detection and risk assessment for all populations. Early childhood caries (ECC) continues to prevail in epidemic proportions. This generally preventable disease is highly morbid and costly. The numerous well-baby visits to the pediatrician during the first years of life offer many opportunities to identify risk for caries and to provide required preventive interventions to avert caries lesions on the teeth, which often progress quickly. Of the hundreds of thousands of children who present with ECC at 2 or 3 years of age, essentially all of them had approximately 6 “healthy” teeth at 1 year.
The caries assessment tools we currently use are based upon historical, environmental, and social circumstances that have been shown to predispose children for ECC. Although these tools are somewhat useful in that they raise awareness of caregivers about the importance of prevention and aggressive intervention, they are mostly highly sensitive but not highly specific. Too many false positives emerge.
A more desirable assessment tool would be one that not only hones in on who is at risk, but one that is able to identify the actual disease process at a very early stage. The extremely complex milieu of circumstances (eg, presence of certain biofilm, salivary factors, frequency of sugar intake, oral hygiene behavior imposed, fluoride regimen) that ultimately leads to clinical manifestation of ECC is nearly always already present by 1 year, when clinical signs of disease are rarely, if ever, perceptible by visual or other currently available means. What is clinically observed as ECC at age 2 or 3 years was likely already developing microscopically below the enamel surface as young as 12 months. The enamel continuously repairs itself via salivary mediated mineral deposition to protect its surface integrity, allowing daily insults of acid attack to be reversed, and averting progression of disease unless this biofilm/sugar-mediated acid attack persists unabated, such as in ECC.
What is needed—and what is currently under rapid development—are technologies that can be deployed to identify the ECC process “microscopically” at a very early stage, as young as at age 1, so that children who will otherwise manifest ECC can be specifically targeted early. Technologies such as laser fluorescence, infrared, and/or near ultaviolet spectroscopy and others are being created and will soon be tested to learn if inexpensive, rapid, and easy-to-use devices using these technologies can “see” the ECC process at 1 year during a well-baby checkup. Such a device could scan the facial and lingual surfaces of the maxillary central incisors to identify the presence and form of ECC subsurface (which is not yet clinically discernible) that if unabated would result in ECC. Loss of fluorescence in the enamel detected by various currently studied devices has been shown to provide reliable information as an analog of caries manifestation and progression.
The work of Eric Seibel at the University of Washington’s Human Photonics Laboratory is an example of an existing technology that is now entering clinical evaluation to test its ability to visualize early caries lesions. His scanning fiber endoscope could help determine patients who should be aggressively targeted not only because of the existence of discrete lesions, but because of the specific predictability that the existence of these lesions at an early stage will lead to ECC if untreated. Prevention methods include a variety of remineralizing and other therapeutics already in existence. Such technology will be useful in engaging providers and caregivers to aggressively intervene when a child is not only identified as high risk, but is already shown to manifest an early of stage disease at a very young age.
The Bottom Line
Rapidly deployed and inexpensive technology for the early detection of ECC during a well-baby checkup will lead to lower costs, lower morbidity, and improvement of oral and overall health for a lifetime.
Joel Berg, DDS, MS, is dean of the University of Washington School of Dentistry in Seattle, Washington.
Cameras are getting smaller, data files can do more
Dental professionals are continually assessing the application of innovative technology for their practice. Digital impression systems are one such technology, as they offer an alternative to conventional impression-taking that is accurate, efficient, and met with significant patient acceptance. Digital impressions are based on the broader workflow of computer-aided design/computer-aided manufacturing (CAD/CAM). By the year 2050, it is predicted that 50% of dental services will involve CAD/CAM technology.1
The Process Today
The CAD/CAM workflow involves three distinct processes. The first process is to use a scanner or camera to record the intraoral condition. The camera transmits the recorded data to a computer software program. The second process involves manipulating the data file to create the desired volume model of the final restoration or prosthesis. The third process fabricates the restoration from the computer design. The most common fabrication process today uses subtractive milling, in which a set of milling diamonds cut away excess material from a premanufactured block of restorative material, leaving the restoration.
Digital impression systems focus on the first process in the CAD/CAM workflow. They are designed to efficiently and accurately record the patient’s teeth and soft tissues to a computer data file. The systems include an intraoral camera or scanner connected to a computer. The computer has a software program to manage the administrative information for the case, such as patient information, and allows for evaluation of the scanned data in a 3-dimensional virtual model. The software program also includes an online laboratory prescription form for ordering restorations from the laboratory. The computer electronically transmits the data file over the Internet to the laboratory for processing. Once the laboratory downloads the data file, it can use it to process models as well as import it to a CAD/CAM program to fabricate the desired restoration.
Getting More Mobile, Accessible, and Versatile
Digital impression systems are mobile units that have a computer in the base of the unit with the camera and monitor on top for easy access and visibility for clinical use. They are self-contained units in which the manufacturer ensures consistent compatibility of the computer, software, and camera. A more recent development is the introduction of modular systems. These systems rely on a “plug and play” type of camera that can be easily moved between multiple computers in the office. Most current digital impression systems utilize a video-type camera to record intraoral structures.
Digital impression systems create large files such as stereolithography (.stl) files. Where and how these data files may be used is one characteristic that sets different systems apart. Some manufacturers restrict the import of their digital files to specific computer programs. This is referred to as “closed architecture,” and it essentially limits the uses of the files as determined by the manufacturer. As digital impression systems have continued to evolve, however, manufacturers have allowed for more widespread import of .stl files in a greater array of software programs, significantly increasing the clinical applications. This is called “open architecture.” Dental laboratories are especially interested in open architecture use of .stl files to limit the number of CAD/CAM programs and devices they need to process restorations from a variety of digital systems. Open architecture systems will likely be a key trend in the future.
Digital impressions are becoming more versatile with expanding clinical applications. Once intraoral data have been recorded with the camera, an .stl file can be used to fabricate any number of laboratory-processed restorations and prostheses. The accuracy of the data file does not degrade with use or over time. The most common uses for digital impressions are fabrication of crowns, onlays, veneers, and fixed partial dentures. However, intraoral scanning abutments have been introduced for implant applications. The encode abutment or scan body is screwed to the implant and a fixture-level digital impression is scanned. The recorded .stl file can be used to fabricate custom abutments as well as resin models for complete CAD/CAM fabrication of the abutment and restoration from a single digital impression. A particular benefit of this process is that it can be done at the time of surgery without contamination of the surgical site.
Additional applications of digital impressions include diagnosis and treatment planning. Several orthodontic software programs accept digital impressions for case planning and appliance fabrication. Some manufacturers have merged .stl files from digital impressions with DICOM files from cone-beam computed tomography scans for diagnosis and case planning for implant placement, abutment design, restoration contours, and surgical guides.
The Bottom Line
Digital impressions offer a very accurate technique to replicate the intraoral condition. The ability to record the dentition with an intraoral camera—without impression material or trays—significantly improves the patient experience. In addition, it is not uncommon for discrepancies in traditional impressions to go unrecognized until the impression has been poured and a model recovered. Digital impressions provide the benefit of visualizing the virtual model on the monitor immediately after the dentition is scanned. The virtual model can be magnified and rotated to determine if critical data for the case have been accurately recorded prior to transmitting it to the dental laboratory. The software program can also provide quantitative feedback on the clearance of the scanned preparation from the opposing dentition. This helps prevent under-reduced preparations from being sent to the dental laboratory, maximizing the success of the desired restoration.
1. Silwadi M. CAD/CAM & Digital Dentistry International Conference website. www.cappmea.com/cadcam8. Accessed June 6, 2013.
Dennis J. Fasbinder, DDS is a clinical professor of dentistry and director of the Advanced Education in General Dentistry Program at The University of Michigan School of Dentistry in Ann Arbor, Michigan.
Get an insider perspective on CAD/CAM and digital dentistry from Daniel Alter, MDT, CDT. dentalaegis.com/go/id805
Using Digital Technology to Enhance Restorative Dentistry [CE] : dentalaegis.com/go/id801
Digital Impression Technology: New Advances: dentalaegis.com/go/id802
Putting It Together: Integrating New Digital and Restorative Options: dentalaegis.com/go/id803
Digital Intraoral Impression Systems: dentalaegis.com/go/id804
New systems maximize resolution, minimize radiation
The modern dental office is now a digital environment, as is the rest of our lives. The same enabling technologies apply inside and outside the dental office—namely, inexpensive computing power and digital storage, both of which are key components of trends in diagnostic imaging.
X-Ray: The Old Standard
Technological evolution in dental diagnostic imaging is continuous, whereas paradigm shifts occur less frequently. The first paradigm shift in x-ray generators was the introduction of intraoral dental radiography in 1896 within weeks of the discovery of the x-ray. The next was in the early 1950s with the introduction of pantomographic scans, and the most recent was the introduction and rapid adoption of cone-beam computed tomography (CBCT) at the turn of the millennium. For most of the history of dental radiography, the recording medium was analog silver halide film which, with the exception of a brief introduction of xeroradiography in the 1970s and 1980s, was the only real option for dentistry until solid state and photostimulable phosphor systems were introduced in the 1990s.
Despite these advances, one should never forget that there are some constants within the imaging chain. First and foremost are the patient and the disease processes that need to be diagnosed, and second, for the most part, the use of x-radiation. X-radiation has been designated by the Food and Drug Administration as a carcinogen, and so its use requires that there should be clinical needs that exceed the risk. No dental radiograph should be made as a routine without prescription by a dental practitioner following history taking and clinical inspection of the individual patient. This is true whether it is a periapical, bitewing, panoramic, or CBCT exposure. When images are made, irrespective of what technology has been selected, the full image or image volume should be read to maximize the diagnostic yield that can benefit the patient.
For the most part, the x-ray manufacturing industry has been striving to minimize radiation dose by using more efficient detectors and better reconstruction algorithms for digital imaging. There are also faster scan techniques that can be used when finer detail is not needed for diagnosis. However, it should never be concluded that digital imaging per se is lower dose or safer than the analog methods it is rapidly making obsolete. The imaging parameters should be set for the task concerned to achieve necessary image quality and area of coverage. Unfortunately, it is possible for the user to overexpose the patient many times over and still have images that are diagnostically acceptable. It is the user, and not the manufacturer, who is most important in restricting dose by proper selection of image parameters after using professional judgment to select which images are needed. Any unnecessary dose should be avoided, and certainly it is inadvisable to use ionizing radiation merely as a substitute for impression materials that do not involve its use.
The Resolution Revolution
Evolution continues for both panoramic and CBCT systems, and in general images are of greater clarity while the doses of radiation required are less. The use of computer-controlled movement and digital receptors has made it possible to provide better projection geometry for panoramic imaging and even to open contact areas between teeth by using specific reconstructions, sometimes misnamed as “panoramic bitewings.” These bimaxillary pro;jections certainly improve clarity of the teeth, but are of far lower spatial resolution than comparable intraoral projections of the crowns of teeth, and certainly do not employ a “wing” that is bitten upon. On the other hand, unlike bitewings, these panoramic bimaxillary projections show the whole of the tooth, including the roots as well as the crown.
Medium- and large-view CBCT scans can be used to reconstruct panoramic images that, unlike traditional panoramic systems, are free from projection distortion, and can sometimes be achieved at doses equal to or lower than standard panoramic systems. Where it has been established that there is no dose disadvantage, the use of CBCT as a substitute for traditional panoramic imaging may be condoned; however, it is still the responsibility of the practitioner to read the full information present to maximize the diagnostic yield from the exposure of the patient to ionizing radiation.
Regarding digital intraoral radiography, for almost two decades there have been the two approaches of photostimulable phosphors (PSP) versus solid-state detectors, and these methods are rapidly making analog film radiography and the associated darkroom and chemical processors obsolete. Where an instant image is desired, the use of solid-state technology is preferred, and generally this is now using a complimentary metal oxide semiconductor (CMOS) chip.
Both PSP and CMOS technologies are mature industries and for the most part all established systems are acceptable, depending on how the sensors fit in your hand and your patient’s mouth and how the software interacts seamlessly with your practice management system. CMOS systems combined with a protective fiber optic and using a structured cesium iodide scintillator are usually preferred for image quality and reliability. One caution to make is that digital intraoral radiology is not necessarily safer than analog film in terms of dose. Both PSP and CMOS detectors have a wide recording latitude, so extreme overexposure can still result in acceptable image quality. Such unnecessary overexposure is obviously not acceptable considering our professional duty to lower radiation doses to as low as practical.
The Bottom Line
Our goal is, and always has been, to produce diagnostic images in situations when professional judgment of the individual patient suggest that scientific evidence exists that benefits of the procedure outweigh the estimated risks. This can be considered “risk within reason.”
Allan G. Farman, BDS, PhD, MBA, DSc, is professor of radiology and imaging science at the University of Louisville in Louisville, Kentucky and is past president of the American Academy of Oral and Maxillofacial Radiology.
Radiation by the Numbers
Every year, 68 million computerized tomography scans are given in the United States; 10% are on children. Source: American College of Radiology
Medical use accounted for 15% of all ionizing radiation in the 1980s, but is estimated to be up to 50% today. Source: USA Today
An individual is exposed to approximately 5 microsieverts of radiation from a dental x-ray, whereas a mammogram provides 3 millisieverts of exposure. Source: PBS
Clinical applications are increasing, but ambivalence persists
Lasers emit a precise beam of light that causes a temperature rise in the target tissue, causing a range of effects from hemostasis to cellular vaporization.1-4 In 1989, the first laser specifically designed for dentistry was cleared by the FDA and subsequently sold in the United States. Although advertised as being able to treat almost every aspect of dental disease, the reality was that this laser would perform only soft tissue surgical procedures. I was one of a handful of dentists to purchase that laser; after 23 years of using the technology, I can say that lasers are definitely an essential part of dental care.
In the present day, estimates are that between 15% and 20% of dentists worldwide own some model of laser. There are approximately 30 indications for their use, including soft tissue surgery, adjunctive treatment of periodontal disease, treatment of aphthous ulcers and herpetic lesions, coagulation, removal of carious lesions and tooth preparation, debridement of calculus, osseous surgery, and endodontic applications.5 Not every laser can perform all of the above listed procedures; however, they can be used for soft tissue applications. Only the erbium family of lasers performs well on tooth and bone. All laser devices have general similarities in terms of delivery systems (optical fiber or articulated arm) and controls. Each manufacturer has specific features that can make the operation of the device easier. The surgical result is not dependent on any of those items.
The two disadvantages to the current offering of instruments are the relatively high cost and the requirement for training. This instruction can vary with each manufacturer, but the clinician should insist on completion of rigorous hands-on simulation exercises to gain an adequate understanding of laser-tissue interaction for the various procedures that he/she intends to perform.
Examining the Evidence
Among the questions I’m asked about lasers is, “Where’s the science?” Many articles point to some of the general benefits of the use of lasers. In dental soft tissue, these include pathogen reduction, hemostasis, less need for sutures, better postoperative courses of healing, biostimulatory effects, and much more safety adjacent to implant fixtures than electrosurgical devices.6-12 For hard tissue, enamel shows no microfractures in a cavity preparation,13 and laser energy applied to dentin and bone produces no smear layer, as well as some disinfection.14
An area of continued controversy is that of laser use for periodontics. Although there are many studies that show effective therapy, there are some meta-analyses of the literature that claim no additional benefit over “conventional therapy.” Confusion seems to abound: a literature review published in February 2013 showed that when compared with no laser use, the adjunctive use of an Nd:YAG laser along with scaling and root planing offered “significant differences in pocket depth reduction…but no difference in clinical attachment gain.”15 However, another clinical study from late 2012 that included bloc biopsy extractions with the same laser and similar protocol showed significant new attachment.16 Other recent manuscripts show the benefit of adding a laser to the initial periodontal treatment protocol.17-22
I’m a firm believer in evidence-based best practices (even though my dental education included such things as mixing amalgam from gelatin capsules of mercury and using high-speed handpieces without water spray). However, the patient’s needs and preferences, the practitioner’s clinical expertise, and the science are all equal components to evidence-based dentistry.23
The safe and effective use of dental lasers is firmly supported by good science. The clinical applications continue to increase, making the laser one of dentistry’s most exciting advances with unique patient benefits. One of the challenges in accurately capturing a digital image of a tooth preparation is getting a clean, dry field in the soft tissue adjacent to the gingival margin. Any laser can easily and quickly provide hemostasis and a clean sulcus. Another example is creating an ideal emergence profile for the final restoration of an implant. A laser allows the clinician to carefully contour the soft tissue in small increments while avoiding any damage to the fixture. Lasers are also useful for the management of the gingival tissue around recurrent carious lesions to allow both complete tooth preparation and placement of restorative materials that are moisture sensitive.
If considering a purchase, one key step is determining what procedures are performed where a laser could be used in addition to or in substitution for the present armamentarium. The practitioner can become more efficient; using a laser in place of retraction cord for a subgingival impression is much faster for control of bleeding and recontouring tissue to access a carious lesion allows placing and finishing of the restoration at the same appointment. Additional production is also possible in that the clinician may perform some straightforward surgical procedures—a frenectomy or fibroma removal—that would have otherwise be referred out of the practice.
The Bottom Line
We practitioners fundamentally believe that our patients are entitled to be made aware of all of the options for treatment. Lasers are a part of those options. We are ethically bound to obtain sufficient education and training so that we meet the standard of care. That standard is subject to both tradition and change, a seeming paradox (think about implants versus a fixed bridge or minimally invasive dentistry.) A clinician must ultimately use a laser in accordance with his or her scope of practice, experience, and training.
Donald J. Coluzzi, DDS, is a clinical professor at the University of California San Francisco School of Dentistry and a charter member and past president of the Academy of Laser Dentistry.
1. Knappe V, Frank F, Rohde E. Principles of lasers and biophotonic effects . Photomed Laser Surg. 2004;22(5):411-417.
2. Springer TA,Welch AJ. Temperature control during laser tissue welding . Appl Opt. 1993;32(4):517-525.
3. McKenzie AL. Physics of thermal processes in laser-tissue interaction . Phys Med Biol. 1990;35(9):1175-1209.
4. Rechmann P, Goldin DS, Hennig T. Er:YAG lasers in dentistry: an overview. In: Featherstone JDB, Rechmann P, Fried DS, eds. Lasers in Dentistry IV. Bellingham, WA: SPIE Press; 2006:2-13.
5. 501(k) Clearances. U.S. Food and Drug Administration Web site. www.fda.gov/medicaldevices/productsandmedicalprocedures/deviceapprovalsandclearances/510kclearances/default.htm. Updated June, 18, 2009. Accessed May 15, 2013.
6. Miyazaki A, Yamaguchi T, Nishikata J, et al. Effects of Nd:YAG and CO2 laser treatment and ultrasonic scaling on periodontal pockets of chronic periodontitis patients . J Periodontol. 2003;74(2):175-180.
7. Ando Y, Aoki A, Watanabe H, Ishikawa I. Bactericidal effect of erbium YAG laser on periodontopathic bacteria . Lasers Surg Med. 1996;19(2):190-200.
8. Romanos G, Nentwig GH. Diode laser (980 nm) in oral and maxillofacial surgical procedures: clinical observations based on clinical applications . J Clin Laser Med Surg. 1999;17(5):193-197.
9. Watanabe H, Ishikawa I, Suzuki M, Hasegawa K. Clinical assessments of the erbium:YAG laser for soft tissue surgery and scaling . J Clin Laser Med Surg. 1996;14(2):67-75.
10. Ross G, Ross A. Low level lasers in dentistry . Gen Dent. 2008;56(7):629-634.
11. Haytac MC, Ozcelik O. Evaluation of patient perceptions after frenectomy operations: a comparison of carbon dioxide laser and scalpel techniques . J Periodontol. 2006;77(11):1815-1819.
12. Christensen GJ. Soft-tissue cutting with lasers versus electrosurgery . J Am Dent Assoc. 2008;139(7):981-984.
13. Keller U, Hibst R. Experimental studies of the application of Er:YAG laser on dental hard substances: II. Light microscopic and SEM investigations . Lasers Surg Med. 1989;9(4):345-351.
14. Stübinger S, Ghanaati S, Saldamli B, et al. Er:YAG laser osteotomy: preliminary clinical and histological results of a new technique for contact-free bone surgery . Eur Surg Res. 2009;42(3):150–156.
15. Sgolastra F, Severino M, Petrucci A, et al. Nd:YAG laser as an adjunctive treatment to nonsurgical periodontal therapy: A meta-analysis [published online ahead of print March 10, 2013]. Lasers Med Sci.
16. Nevins ML, Camelo M, Schupbach P, et al. Human clinical and histologic evaluation of laser-assisted new attachment procedure . Int J Periodontics Restorative Dent. 2012;32(5):497-507.
17. Eltas A, Orbak R. Clinical effects of Nd:YAG laser applications during nonsurgical periodontal treatment in smoking and nonsmoking patients with chronic periodontitis . Photomed Laser Surg. 2012;30(7):360-366.
18. Kreisler M, Al Haj H, d’Hoedt B. Clinical efficacy of semiconductor laser application as an adjunct to conventional scaling and root planing . Lasers Surg Med. 2005;37(5):350-355.
19. Kamma JJ, Vasdekis VG, Romanos GE. The effect of diode laser (980 nm) treatment on aggressive periodontitis: evaluation of microbial and clinical parameters . Photomed Laser Surg. 2009;27(1):11-19.
20. Saglam M, Kantarci A, Dundar N, Hakki SS. Clinical and biochemical effects of diode laser as an adjunct to nonsurgical treatment of chronic periodontitis: a randomized, controlled clinical trial [published online ahead of print November 16, 2012]. Lasers Med Sci.
21. Lopes BM, Theodoro LH, Melo RF, et al. Clinical and microbiologic follow-up evaluations after non-surgical periodontal treatment with erbium:YAG laser and scaling and root planing . J Periodontol. 2010;81(5):682-691.
22. Kelbauskiene S, Baseviciene N, Goharkhay K, et al. One-year clinical results of Er,Cr:YSGG laser application in addition to scaling and root planing in patients with early to moderate periodontitis . Lasers Med Sci. 2011;26(4):445-452.
23. About EBD. ADA Center for Evidence-Based Dentistry. http://ebd.ada.org/about.aspx. Accessed May 15, 2013.
Laser Technology: Its Role in Treating and Managing Periodontal Disease: dentalaegis.com/go/id806
Academy of Laser Dentistry Resources for Professionals : dentalaegis.com/go/id807
Why Are Lasers Still Controversial?: dentalaegis.com/go/id808
5 key questions to answer before investing
During the past 25 years, practice management software has revolutionized dental practice operations in the areas of scheduling, accounting, patient communication, and data management. According to the Levin Group Data Center™, more than 90% of dental practices now have some form of practice management software.
Staying Ahead of the Curve
Although practices have made significant gains in efficiency, technology also presents challenges. Practice software must be regularly upgraded or replaced in a similar timeframe. If not, inefficiency begins to take over processes and protocols, reducing staff productivity and effectiveness.
In the aftermath of the Great Recession, many dentists postponed making practice investments. Trying to get by with outdated software is a self-defeating proposition, however. The longer an inefficient system is allowed to exist, the greater the problem becomes.
To put their practices in the best position for success, dentists must provide their teams effective tools for successfully performing their duties. In today’s digital offices, updated practice management software is a requirement. Before purchasing practice management software, dentists must ask these five questions:
1. What features am I looking for?
Today’s practice management software provides a wealth of functionalities, from appointment scheduling, perio charting, and visual imaging to patient recall, electronic insurance claim submissions, and patient billing. As more and more offices consider going paperless, almost every administrative function can be migrated to a digital realm.
2. Is the software easy to use and how is the support?
Most practice management software has been designed to be user-friendly. But practices should “test-drive” any software before purchasing. In addition, dentists need to know how the software will be supported once it is purchased. Does the company provide in-office or web-based training? Does it have sales representatives who regularly visit the office or is support only available by phone? Does it have a proven track record when it comes to customer satisfaction? In addition, practices should examine what type of warranty the company provides.
3. Can it be integrated with other technologies?
When selecting software, dentists should make sure it integrates with other technologies in the office. Although this is a chief concern of many dentists, it often occurs too late—after a purchase has been made. Having also advised numerous dental companies over the years, I can say that when new technologies do not integrate with the practice management software, they fail in the marketplace. This question needs to be asked before—not after—purchasing software.
4. Can it easily provide the data I need?
Without accurate practice data, good decision-making is undermined. Software that could deliver essential practice data at the press of a button would be an invaluable tool. For example, according to Levin Group Data Center™, the national average of the number of new patients declined 5.1% for practices in 2012. This means that practices need to be much more effective at retaining current patients. Software that can run reports on overdue and inactive patients, enabling the practice to get them back on the schedule, would be highly valuable.
5. What is the cost and will it provide an adequate ROI?
A return on investment is vital because it contributes to the practice’s financial stability. Dental practices operate with significant overhead. Therefore, each new technology purchase should be able to provide a timely return on investment (ROI). Most software systems are similarly priced, but that does not mean they provide a similar value. In addition to the initial price, there can be hidden costs, such as yearly upgrades that may be necessary but expensive.
The Bottom Line
The right practice management software will increase office efficiency, team effectiveness, and practice production. No matter what new systems come to market in the future, these five questions will help dentists make the best decision regarding their purchase.
Roger P. Levin, DDS, is a third-generation general dentist and the chairman and chief executive officer of Levin Group, Inc.
Advances in hardware and 3D software removes barriers
The lifecycle for adopting a new technology includes innovators, early adopters, a majority, and laggards. It can be argued that implant surgical guides remain in the early adopter phase and we will soon see the early majority (suggested to be more than 1/3 of a profession) begin to use and prefer the use of surgical guides.
Planning Goes 3D
Planning for implant therapy is essential. Ultimately, accurate dental implant placement can be facilitated or enhanced using 3-dimensional (3D) surgical guides created using volumetric imaging through computer-aided design/computer-aided manufacture (CAD/CAM).1 The value of using 3D guides is reflected in greater (not absolute) accuracy and by an often expedited surgical experience. A recent review of this technology indicates a spectrum of approaches to achieving surgical guidance during implant placement.2 Use of 3D planning and derived surgical guides offers benefits of improved planning options, safety, accuracy, and speed. Depending on the clinical scenario, each of the benefits acquires more or less value for the implant team.
The clinical process required to create a useful surgical guide offering 3D guidance is a multistep process that requires envisioning the final prosthesis. Although traditionally achieved by diagnostic waxing or trial tooth arrangement, newer approaches include virtual tooth arrangement. Some mechanism (duplication, scanning, or design) is needed to place and align a 3D rendering of the envisioned prosthesis within the 3D image of the jaws and teeth. Without careful restorative protocols, this essential step can introduce or promulgate errors that corrupt the intended plan.
The essence of planning involves placement of implants within visualized bone such that the implant axis is congruent with the geometric constraints of the prosthesis. 3D planning software provides an enriched environment for planning; obstacles are noted, distances can be calculated, and implants of different dimensions may be evaluated. Visualization is enhanced directly and conceptualization expands. This is particularly important in the communication among the engaged clinical team.
Multiple solutions can be explored with great facility and remarkable ease. The interactive and iterative nature of computer-based planning for dental implants represents one advantage over conventional planning using planar radiographs and study casts. More significant perhaps is the collaborative potential and communication opportunities made available by this planning technology. The multi-disciplinary nature of dental implant therapy is realized here and the patient may be included in the visualization of the ultimate plan or plans.
Surgical guidance is derived from the 3D plans generated from planning software. The accurate replication of contemporary scanning prostheses in a digital format informs CNC manufacture by milling/drilling or lithographic procedures of surgical guides that enable surgical procedures developed from osseous support, tooth support, or mucosal support. The advantages of mucosa-supported guides include reduced surgical morbidity and increased safety by improved accuracy during a “closed” procedure.
Advantages and Barriers
The noted advantages of implant surgical guides include safety and accuracy. Measures of accuracy indicate that there are current practical limitations that should be carefully regarded.3 However, some newer protocols have illustrated that it is possible to design a prosthesis, plan implant placement, and deliver the implants and a well-fitting prosthesis according to the digital model. This achievement affirms the importance of visualizing the restorative plan congruent with implant planning.
If dentistry has the technology to place implants according to enhanced planning with improved accuracy or using expedited surgical procedures that may offer reduced morbidity, then why is this not fully adopted in clinical practice? There are certainly many facets to this question. Among them are financial and practical matters that include the logistics (or workflow), time, and cost associated with planning, scanning, producing the guide, and performing the procedure. Continued streamlining of software and integration of hardware (eg, increased communication among cone-beam computed tomography [CBCT], scanners, and mills or printers) are lowering these barriers to surgical guide use.
Education is another barrier to use and generational differences come into play. The youngest of dentists—born with a computer mouse in one hand and a smartphone in another—find the technology comfortable. We older dentists have found more formal training necessary in adopting this technology. Still another perceived barrier to use is that of access. Special software and hardware are today widely available in most communities. Beyond access to CBCT, the remaining pieces of technology are also widely available through our valued dental laboratory technicians. There are few capital expenditure investment barriers to becoming fully engaged with digital technologies and surgical guides.
The Bottom Line
Adopting new technology is an interesting cultural phenomenon and the dental implant surgical guide offers an example of this process. The forces that may influence adoption of this technology include a growing outcomes database,3 patient awareness, professional risk aversion, logistical improvements, and cost reduction.
I use surgical guides. Some;times. The reasons may reflect some of the reasons stated above. If they reflect any perceived logistical barriers to use, I surely remind myself that these barriers are being eroded by improvements in software, the integration with and improvement of hardware, and the widespread adoption of both by radiologists and dental technicians.
Lyndon Cooper, DDS, PhD, is the Stallings Distinguished Professor of Dentistry of the Department of Prosthodontics at the University of North Carolina at Chapel Hill, where he serves as director of graduate prosthodontics.
1. Ganz SD. Presurgical planning with CT-derived fabrication of surgical guides . J Oral Maxillofac Surg. 2005;63(9 suppl 2):S59-S71.
2. Orentlicher G, Abboud M. Guided surgery for implant therapy . Oral Maxillofac Surg Clin North Am. 2011;23(2):239-256.
3. Vercruyssen M, Jacobs R, Van Assche N, van Steenberghe D. The use of CT scan based planning for oral rehabilitation by means of implants and its transfer to the surgical field: a critical review on accuracy . J Oral Rehabil. 2008;35(6):454-474.
H. Ryan Kazemi, DMD, MD, demonstrates common problems that can occur with implant surgical guides. dentalaegis.com/go/id80
Emerging TechnologyLab-Grown Teeth Could Change the Future of Implants
Researchers from King’s College London have successfully created—and transplanted—new teeth that were grown in a lab without using traditional embryonic stem cells. Their research, which was published in the Journal of Dental Research, describes a technique that combined human epithelial cells with embryonic mesenchymal cells from mice.
Mesenchymal cells are undifferentiated connective tissue cells that are derived from the mesoderm. When combined with mesenchymal cells, the human gingival epithelial cells began developing into a tooth. Although the mesenchymal cells used in this study were embryonic in nature, wisdom teeth are a potential source of adult human mesenchymal cells.
When researchers implanted the cultured cells, the resulting human/mouse hybrid tooth had its own root structure. If this technology were to become readily available and affordable, it has the potential to revolutionize the implant industry.
Devices allow detection at earlier stages than ever before
s dental practitioners, all too often we get caught up in what procedures we are performing and sometimes overlook our most important and vital function—a thorough assessment and management of the patient’s overall oral and related systemic health. Arguably, the most important condition to detect at its earliest stages is cancer and the disorders that have the potential to progress into this deadly disease. However, the clinician’s true goal is to discover and manage any abnormality or condition that the patient has, no matter how benign or trivial it may be. New technologies have been critical in meeting this goal.
Detection, Assessment, Diagnosis
Over the past few years, there have been several technological advances that are giving clinicians the ability to detect and diagnosis conditions at early stages that were never dreamed possible before. As our patient’s systemic and oral health situations are becoming increasingly more complex, due in part to a longer life expectancy, an increase in multiple chronic and/or acute conditions, and the use of an increased number of medications, the need and desire to have advanced technologies to assist the practitioner has never been greater.
Today’s enhanced diagnostic modalities include specialized illumination and visualization technologies that allow practitioners to enhance their clinical exam, new salivary and cellular collection techniques, and computerized databases that forewarn of possible oral conditions, side effects, and interactions that may be caused by a patient’s medications and systemic conditions.
The diagnostic process involves 3 very distinct steps that often get blurred together, which causes much confusion, especially when evaluating diagnostic modalities. The first step in the examination process is detection, which has the objective of determining whether or not any abnormal process or disease condition is present. The second step is the assessment of the discovered condition, which is to characterize the situation that exists. One of the primary goals of this assessment process is to determine what other screening and examination techniques should be performed. The third step is diagnosis, which is when a healthcare professional or professionals compile all the information available from multiple sources and assessment techniques to arrive at a consensus decision.
For a general practitioner (GP), the primary objective of the enhanced examination is to confirm that the patient is in a healthy state free from any abnormalities, not to provide a definitive diagnosis for a condition. When evaluating the technologies available, the GP’s primary focus should be for the detection of an abnormality. The expectation that a single adjunctive screening modality by itself will provide a definitive diagnosis, while it may be desirable, it is entirely unrealistic.
A full thickness surgical biopsy with intact architecture is the gold standard for the diagnosis of oral cancer. All of the clinical assessments and technologies are adjunctive modalities that may help determine if, where, and when a surgical biopsy would be appropriate.
Screening for Breadth and Depth
The concept of adjunctive screening technologies is divided into 2 basic categories. The first is a field-of-view technology that assesses a wide region or area, the second is a site specific technology that focuses on a limited area once an area of concern has been detected.
A field-of-view screening technology’s initial role is to assess a wide region to discover any abnormality or irregularity. Some of these modalities also have the ability to additionally give the clinician some site-specific information once an area has been detected. An example of this type of device is a fluorescence mucosal screening technology. Following the clinician’s visual and tactile exam, these instruments are initially used to perform a cursory fluorescence screening looking for any abnormal fluorescence patterns or responses. An unexpected change in the auto-fluorescence pattern in the tissue being examined may indicate that there is an abnormal process occurring in the area. The location, size, shape, and type of fluorescence pattern may suggest what questions should be addressed or additional information should be collected, but it does not render a definitive diagnosis.
Another example of a field-of-view technology is an aceto-whitening process where the patient rinses with a mild acetic acid solution to slightly desiccate the tissue in an effort to make a white lesion more prominent when examined under enhanced illumination.
If such an area of concern is discovered with any of these field-of-view screening techniques, the clinician re-examines the specific area with a more intense focus on the findings with all of the modalities necessary and available to establish a clinical impression or working diagnosis for the area of concern.
Cellular, bacterial, viral, salivary, and genetic assessments are laboratory tests that also provide the clinician with additional information to aid in establishing the proper diagnosis and management of many conditions of both oral and systemic nature.
Before any of the enhanced screening technologies are incorporated into a practice, establishing patient communication processes is imperative. This includes both how the technology is introduced to the patient and what is said and done when an area of concern is discovered. Never tell the patient you are performing an “oral cancer exam,” as we are examining the patient for a variety of conditions not just cancer.
A more positive and nonintimidating way to describe the in process is to tell the patient that you are performing “an enhanced comprehensive oral examination, looking for everything from cavities to periodontal disease to a cheek bite to cancer.” When an area of concern is discovered, it is much more likely be another condition rather than cancer, and the patient is not unnecessarily alarmed until the definitive diagnosis is made.
The Bottom Line
The diagnosis of a condition is never established by a single modality or examination process or, more importantly, a single device. This concept should not be overlooked when clinicians are evaluating which detection or assessment technologies might be most appropriate and beneficial for their practices. A thorough understanding of the benefits and limitations these devices is mandatory, and the clinician’s knowledge of the disease process is the foundation of the examination process, not the technology used to gather the information.
Scott D. Benjamin, DDS, has worked in full-time private practice for more than 25 years. He is a member of many associations, including ADA committees addressing dental informatics, digital photography and imaging, and electronic health records. He is also on the board of directors for the Academy of Laser Dentistry.
The American College of Prosthodonists demonstrates how to conduct a thorough oral cancer screening exam. dentalaegis.com/go/id810.
DentalChart provides a flexible, customizable way to maintain electronic patient records. Charts can include a record of procedures, a color-coded materials list, photo galleries, and more. The app is password protected and all information can be backed up to a computer or iCloud.
DentalSTAT eliminates the need for manual calculations for patient-specific doses of common dental medicines. Clinicians determine proper dosages by selecting drug category, type, and patient weight, when applicable. Results are displayed in a pharmacy-friendly format.
For: iPhone, iPad, iPod touch;Android devices
Dental CT View
Dental CT View provides a resource for previewing CT and CBCT scans over the Internet in a secure and rapid way. Within minutes, it provides preview panoramic cross sections with intuitive pan-zoom viewing with password protection to keep data secure.
For: iPhone, iPad,iPod touch
Dental Spanish Guide
Dental Spanish Guide is designed to increase communication between practitioners and their Spanish-speaking patients. The guide contains questions, instructions, and explanations logically divided into easy-to-find chapters covering from the pre-exam through discharge.
For: iPhone, iPad, iPod touch; Android devices
Dentapedia helps dentists to explain dental procedures and treatments with patient-friendly interactive videos. The app includes more than 100 high-quality 3D animations, and is available in six languages for working with a variety of patient populations.
For: iPhone, iPad,iPod touch