Technology in Practice: Its Impact on Dentists, Patients, & The Profession

Introduction Allison M. DiMatteo, BA, MPS

The future potential of the dental profession is endless. Broadening the horizons are discoveries and technological advancements that can be applied to everything from diagnostics to impression taking, restoration design and fabrication to 3-D imaging, and beyond. However, maximizing the benefits of today’s innovations for dentistry requires clinicians to be knowledgeable about what’s available, what’s possible, and how to best apply it in clinical—or laboratory—practice.

For example, dental CAD/CAM (computer aided design/computer aided manufacturing) has changed a lot since its introduction approximately 25 years ago. Today, there are quite a few dental CAD/CAM companies competing against each other, and this has affected dental laboratories profoundly, explains Ed Flocken, CDT. Consequently, as a result of so much competition, many practices are starting to wake up that probably would never have looked at a technology like this, he says.

“I think the statistics for milling teeth indicate that about 28% of all laboratories have some form of CAD/CAM device or service available to them, and we’ve seen a lot of restorations now being made out of zirconia instead of porcelain-fused-to-metal,” Flocken observes. “That, in itself, has changed dentistry a lot.”

When Flocken attended the International Dental Show (IDS) meeting this last year, he counted upward of 140 companies entering the dental marketplace with some type of CAD/CAM-related device. Such variety and potential complexity of CAD/CAM choices could leave dentists and laboratories sitting on the fence as they try to decide exactly what technology to invest in. Until they make the leap, he says, dentistry will likely see more outsourcing and more dentists trying to work with laboratories that have CAD/CAM equipment or supply the equipment.

“My father always said to me that the one thing I need to understand about dentistry is that we can only make as much as our two hands can produce,” Flocken fondly recalls hearing his father say. Flocken’s father was a professor emeritus at UCLA School of Dentistry for 22 years. “I knew I could no longer produce as much work as I wanted to make in income. I also knew I could not compete with large laboratories in terms of price and turnaround unless I used technology.”

In addition to increasing productivity in the dental office and laboratory, dental technologies also have changed the image of dentistry, sometimes significantly. For example, according to Michael Swick, DMD, dental lasers represent dentistry’s move toward more high-tech equipment than what’s been used in the past.

“People perceive that lasers are better, which they are. They are more precise. They can be used to perform different tasks than older methods, and they perform them very well,” Swick explains. “The precision is important, and in my practice, I found that I can do more difficult procedures than I could in the past, such as different types of surgery and bone removal.”

In addition to enabling the simplification of previously complex procedures, dental lasers also expand the scope of procedures that general dentists can provide for their patients, Swick emphasizes. In the more than 10 years that he’s been teaching laser dentistry to general dentists, he’s provided instruction in such areas as the obvious gingival recontouring, periodontal therapy, and correcting external resorption—the latter case being one in which teeth may have been extracted in the past.

“Dentists are doing many more procedures than in the past, and they’re doing them in a very productive way because the laser treatments and restorative procedures can be performed in the same day, with very good, predictable results,” Swick elaborates. “Patients are more apt to undergo some of these procedures, whereas in the past, if they thought they would hurt or bleed, they would decline those procedures.”

Just as dental lasers have increased a dentist’s productivity, so too has digital impressioning. And, like lasers, dental impressioning also has provided clinicians with enhanced accuracy. This, according to Nathan Birnbaum, DDS, is the name of the game in restorative dentistry, as well as representing a time-saving factor, also.

“A tremendous advantage with digital impression taking is accuracy. In my field of prosthodontics, having the assurance that crowns fit as precisely as possible is a major plus. With a digital impression, it’s almost foolproof that we obtain much more accurate impressions,” Birnbaum observes. “In addition, the ability for dentists to have an enlarged, magnified view of the tooth preparation prior to taking the impression also enables us to assure that the preparation is nice and confluent, that the margins don’t have any defects in them, and that we’re in sound tooth structure all the way around our preparation, without undercuts.”

These are advantages not normally seen with an elastic impression. In addition, Birnbaum says that the amount of time required to seat crowns fabricated from digital impressions also has been reduced, because the contacts and bite are more accurate. Therefore, there is much less adjustment or addition of materials required to achieve nice interproximal contacts, he elaborates.

“We’re finding that digital impressions are a timesaver, not only in terms of the amount of time required to take the impression, which is considerably less than it used to be with the elastic materials, but also during the appointment for seating the crowns,” Birnbaum notes.

Thus far, the technologies being introduced into dentistry are enabling greater precision, productivity, and time savings than methods from generations past. They also are enabling clinicians to undertake new procedures, or accomplish them in new ways. Such is the case with cone beam CTs and digital radiographs, which can potentially act at least as a basic impression, as well as a diagnostic tool, explains Allan G. Farman, BDS, PhD, MBA, DSc, a professor of radiology and imaging science in the department of surgical and hospital dentistry at the University of Louisville.

“In the past, when talking about imaging, one was referring to lone practitioners with an X-ray machine in their office and developing analog film, which had to be duplicated and sent to an insurance office,” Farman recalls. “Now, we are talking about 3-D imaging, something that is not just diagnostic, but also enabling treatment planning and image-guided treatment.”

With such imaging and planning capabilities comes increased acceptance and use of state-of-the-art treatments, such as implant restorations, at the general practice level, Farman has observed. In fact, at the general practice level, clinicians are moving from doing rudimentary amalgam and composite restorations to providing implants with the aid of fabricated stents that ensure more precise placement, he says. This usually requires the transmission of those 3-D images to a laboratory that may be in the United States, possibly in the same state, maybe in a distant state, or perhaps in another country.

“The 3-D imaging, especially the large field-of-view cone beam CT systems, really links the dentist to the healthcare profession, in general, if the dentist is adequately trained or adequately refers the images to be read by a specialist in oral and maxillofacial radiology,” Farman says.

Other diagnostic tools—such as salivary diagnostics—are coming into their own and will enable dental professionals to evaluate risk and counsel patients in ways that are new and different than they’ve done in the past, explains Scott Benjamin, DDS, a private practitioner from Sidney, New York, and a well-known lecturer on the subject of dental technology. Dentistry in the past had been a reactionary profession, one that saw problems and corrected the problems, he says. Today, salivary diagnostics, HPV testing, and DNA testing are giving dentists the ability to evaluate the patients who are potentially at risk, change the methodology of treatment, and, more importantly, possibly change the behavioral attitudes or actions of the patient and hopefully intervene and stop the progression of the disease, Benjamin elaborates.

“To be able to look at patients’ risk for the genetic susceptibility for periodontal disease and oral cancer, for example, hopefully will allow us to counsel our patients better on the oral diseases that we’re very familiar with and to manage them,” Benjamin says. “Unfortunately, much of our training has not been in that type of approach and, more importantly, the reimbursement pathways in dentistry have been more procedure-driven than diagnostic-driven, and that’s something that has to change.”

According to Benjamin, some of the information derived from caries susceptibility tests enables an examination of what is contained in the saliva and what the bacterial composition of the plaque is, rather than just the bacterial load. This type of information can help dentists provide therapies to change the bacterial concentration and reduce the incidence of diseases such as periodontal disease and dental caries. Additionally, at a time when the incidence of oral cancer is rising tremendously because of HPV, among other factors, clinicians can be screening for the underlying mucosal diseases that can lead to cancer and, hopefully, correct them at that early stage, Benjamin asserts.

Clearly, a lot of new equipment has emerged in the last several decades that is commonly used in the operatory, but they haven’t always been very well integrated, notes Lance M. Rucker, DDS, professor and director of clinical ergonomics and simulation at the University of British Columbia Faculty of Dentistry. It’s very difficult for a manufacturer to integrate equipment into a setting where there could be any sort of delivery, any sort of platform, in any sort of physical layout. In anticipation of that, the general rule has been to create devices (eg, lasers, 3-D cameras, surgical microscopes, surgical telescopes, paraphernalia associated with implant placement) that are as compact as possible, as portable as possible, and usually as any-which-way deliverable, he explains.

“That strategy may seem innocuous, but it actually has a profound negative effect on any sort of logical integration that can default to balance for the operator or the clinician, rather than imbalance. It’s the imbalance that’s the scourge of what we do and causes problems not only for the primary operator but also for the treatment end product for the patient,” adds Rucker. “A primary operator who is very sore on Friday afternoon is not somebody that you want to have as your dentist.”

However, there are many combinations of most modern equipment that can be made to work and optimized for an operator, Rucker emphasizes. It is usually possible for the layout problems to be neutralized and solved so that people can work largely, if not completely, musculoskeletal symptom-free, which is probably one of the more novel concepts that has been open to dentists, he adds.

“Clinicians are beginning to accept that perhaps they can be both comfortable and healthy at the end of the workday and the end of the workweek, and not because of certain magical equipment,” Rucker emphasizes. “Rather, they can realize this by having equipment laid out, set up, and utilized in ways that create a setting in which the equipment and the operatory works for them, rather than the other way around.”

This month, six key opinion leaders in the areas of digital imaging, diagnostics, digital impressioning, office ergonomics, CAD/CAM, and lasers each discuss what is new in their respective technology category, as well as issues that may influence integration and adoption throughout the profession. In addition, to best assist readers in integrating the technology into practice, they outline what is needed in terms of education and training so that dentists and their patients can each realize maximum benefits.

Today’s Advanced Diagnostic Technologies
Scott Benjamin, DDS

The Revolution in Digital Impressioning
Nathan S. Birnbaum, DDS

3-D Imaging in Dentistry
Allan G. Farman, BDS, PhD, MBA, DSc

CAD/CAM Restorative Dentistry
Ed Flocken, CDT, BA

Ergonomics and Operatory Equipment Systems:
Technology Impact on Dental Practice
Lance M. Rucker, DDS

Dental Lasers
Michael Swick, DMD