Binary Work: The applications of digital dentistry for the dental team continue to become mainstream

By Trish Jones, RDH, BS

It is quite amazing to think about the dentistry performed today as compared to 30 years ago or even 10 years ago. The evolution of integrating digital applications has had a profound impact on patient care in the dental office. Digital dentistry-from in-office digital charting to digital X-rays and impressions-has made patient care more efficient and streamlined.

Think about the added value of comfort to the recipients of the care digital offices are providing. It is, however, a challenge for the dentist to keep up with the plethora of digital technologies available, let alone the dental team of administrative personnel, dental assistants, dental hygienists, hygiene assistants, and sterilization assistants. The success of incorporating a new technology in the office is dependent on the knowledge base of not only the dentist but the entire dental team. Knowledge of the digital workflows of the different technologies enhances the confidence and use of these technologies.

What are digital technologies? It is when data is generated, stored, and processed in a string of binary digits such as 0 and 1. What exactly does this mean? Basically, immense amounts of data can be easily preserved and transported, which makes data transmission quicker. In the dental world, this means using any digital technology or device that involves computers versus mechanical or electrical stand-alone technology or service. This has transformed how people communicate, learn, and work.

In the dental field, digital has streamlined many processes. It has interconnected and intertwined services like a spider web. In the workforce, some embrace technology as soon as it becomes available, while others do not embrace it until they are compelled to due to a current system becoming obsolete, or it has proven to be a successful technology and/or a lower cost of investment.

This article covers the basics, but it is not all-inclusive as digital technologies continue to expand and grow exponentially. By the time this article is published, several new and updated technologies will be introduced. Need a comparison? Think of your cell phone, which is most likely a smartphone. Soon after you purchased the latest one, the next model was released. What about your television? Can you imagine how we lived without flat screens?

We live in a world of instant data. We want information now, and we want it efficiently. A priority during an evaluation of the dental office is to transform the business to embrace the digital revolution. There is no turning back, and it is more of a "when" rather than an "if" we are going to implement this technology. Digital dental technology offers practice-enhancing business tools that improve customer service, the diagnostic process, and the whole patient experience. Patients notice if you are on the cutting edge of technology or if the office is using antiquated procedures.

Digital Charts/Practice Management Software

Long gone are the days when appointments were recorded in scheduling books manually. However, some offices have not converted. Computer-specific software for the dental office has evolved how we enter appointments. Not only can we make appointments, but everything pertinent to the patient's dental well-being can be recorded as well. It is about practice management.¹²

A few systems currently on the market have made a streamlined process of providing efficient patient care. Many claim no need for paper charts. In general, these types of software track appointments, patient records such as charting and radiographs, billing and insurance, reports on practice growth, and more.

Opportunities exist for offices to schedule multiple dentists in multiple rooms according to time units needed per procedure. Accounting reports can be easily created to track services, charges, and payments, as well as practice analysis. Patient records from intraoral camera photos to digital radiographs, periodontal charting, and clinical notes are stored in one spot, or are web-based such as on the cloud. The day of the "missing chart" is gone. Information is digitally stored and easily retrievable. More than a few companies even offer a mobile version.

Examples of practice management software are:

• Eaglesoft by Patterson (patterson.eaglesoft.net)

• Dentrix by Schein (dentrix.com)

• Practiceworks by Carestream (carestreamdental.com)

• Curve Dental (curvedental.com)

Dental practice software has evolved so that it can provide solutions for patient education and team education. Which one is the best? That is dependent on the dentist's and the dental practice's needs and wants. It is based on the level of confidence and flexibility of your practice's lifestyle, work, and personal lifestyle.

Digital Radiography

A cornerstone of diagnosis and treatment planning is the use of radiographs. Traditional radiographs consisted of radiographic film that was manually processed, involving several film-processing steps. Today, dental offices have access to digital radiography. The advantages of using a sensor to capture data are immediate viewing, time reduction, and storage.

Examples of digital radiography systems include:

• Gendex (gendex.com)

• Schick by Sirona (schickbysirona.com)

• Dexis (dexis.com)

• Logicon by Carestream (carestreamdental.com)

Some sensors are wireless. Some X-rays units are handheld. Digital images include intraoral radiographs or panoramic radiographs. The images can be transferred to other rooms, such as the dentist's private office for viewing, or even emailed to specialists for consultation using a HIPAA-compliant email service.

Images can be enlarged and enhanced to provide a comprehensive diagnosis and evaluation. To further add to the enhancement of digital radiography, a computer-aided diagnostic tool such as caries detection software is an option. Patients appreciate the fact that less radiation is used since the sensors are more sensitive and provide a quality image.^13,18

Cone-Beam Computed Tomography

With implants increasingly becoming a more popular treatment in dentistry, so is the diagnostic tool of cone-beam computed tomography (CBCT). CBCT involves using rotating X-ray equipment (panoramic and cephalometric) where the X-rays are divergent, forming a cone combined with a digital computer to obtain cross-sectional images of body organs and tissues in 3D. In dentistry, it is used in the head and neck region.

Examples:

• iCat (i-cat.com)

• Carestream (carestreamdental.com)

• Gendex (gendex.com)

• Planmeca (planmeca.com/na/)

Views of soft tissue, bone, muscle, and blood vessels can be readily evaluated. These images assist in implant, orthodontic, periodontic, and endodontic treatment planning. They may also assist in evaluation of the temporomandibular joint, airway, and sinus.⁶ CBCT uses a fraction of the dose of a conventional CT. Some models can incorporate the face in 3D as well as scan models and/or imprwessions.

Implant Treatment-Planning Software

The success of an implant case is dependent on correct placement as well as several other factors such as osseointegration. Presurgical treatment-planning software is designed to increase the efficiency of placing implants.

Since modern implant technology was introduced by Dr. Per-Ingvar Branemark, implants have grown remarkably as a viable option for missing tooth replacement. There are many brands of implant systems to choose from today.

Examples of implant-planning software include:

• 3D Diagnostix (3ddx.com)

• Anatomage (anatomage.com)

• BlueSkyPlan (blueskybio.com)

• coDiagnostiX (codiagnostix.com)

• iDent (ident-surgical.com)

• Simplant by Dentsply (dentsplyimplants.com)

• SICAT by Sirona (sicat.com)

Surgical templates assist in proper placement for esthetics, restorative, and functional purposes, making implant placement faster, easier, safer, and more precise. From dental scanning to planning to drilling and implant placement, implant treatment-planning software can enhance the process and increase the accuracy of placement.¹⁵ Treatment-planning software incorporates a digital scan either from an intraoral digital scanner or from a 3D image from a CBCT scan. Some implant companies have their own systems while other companies provide universal systems with digital catalogs of dental implant options.

Intraoral Scanners

The use of CAD/CAM (computer-aided design/computer-aided manufacturing) dentistry is one of the fastest growing aspects of dental technology. Since the launch of CEREC 1 in 1985, the ease and use of intraoral digital scanners have significantly increased over the years. One of the most important factors in restorative dentistry is taking the final impression to send to the lab or to a chairside milling machine.

Examples of digital scanners include:

• CEREC (sirona.com)

• Carestream CS 3500 (carestreamdental.com)

• iTero by Align Technology (itero.com)

• The DWIO system from Dental Wings (dentalwings.com)

• 3M True Definition (3m.com/3M/en_US/Dental/)

• Trios from 3Shape (www.3shape.com)

• PlanScan from Planmeca (planmecacadcam.com)

• Lythos by Ormco (ormco.com)

Mechanical impressions utilizing traditional impression materials (polyvinyl siloxane or polyether) are technique sensitive and have variables such as setting time, proper placement, hydrophilic/hydrophobic properties, and properly following the manufacturer's instructions. Any deviation can lead to discrepancies in the final impression, causing distortion of the impression and the final restoration, resulting in chairside adjustments or the inability to seat properly. This leads to additional time on the case and loss of profitability.

Intraoral scanners utilize digital scanning concepts, some proprietary to individual companies, to capture a digital replica/impression of the teeth and/or preparation. Scanners streamline the digital workflow on a case. Chairside milling capabilities such as the CEREC or E4D technologies are available, or direct submission of a case to a dental laboratory from a scanner is another option.

The prescription is completed on the scanner and after the 3D scan/impression is complete, the digital impression and prescription are submitted and uploaded via internet connection from the software to the laboratory of choice. Once the laboratory receives the information, the impression and/or margins are verified and the scan can be imported into a software program where the restoration can be designed on the computer and then sent to a milling machine for fabrication.

If physical models are required, they can be milled (iTero, Align) or they can be printed via a dental 3D printer. Restorations that drive the CAD/CAM industry include ceramic and monolithic options such as zirconia and lithium disilicate (such as the IPS e.max system by Ivoclar Vivadent).

The advantages of using a digital scanner are accuracy, speed, and ease of use.¹¹ The dentist is able to view the case prior to sending. What does this mean? Changes can be made and recaptured prior to sending the case to the lab or to the in-house milling unit. Several intraoral scanners are on the market, and it can be a challenge to decide which one is best for the practice. It all comes down to which one the dentist and team will use and what dental applications (such as for restorative only, or restorative and orthodontic purposes) are required. Variations in wand size and weight, portability, and open architecture are other factors to review. All scanners require proper training and the team's embracing the technology to make it successful regardless of which system is purchased.⁴

Orthodontics

Orthodontics also utilizes the benefits of digital technology. Traditional impressions can be scanned or digital impressions can be scanned, and treatment planning can be done using CAD/CAM technology. Intraoral scanners allow impressions to be submitted digitally. This significantly speeds up the pretreatment process with digital bracket placement and/or aligner fabrication and start of treatment. It also enhances the accuracy of the process.

Systems developed for orthodontics include:

• Insignia by Ormco (ormco.com)

• Invisalign (invisalign.com)

• ClearCorrect (clearcorrect.com)

Intraoral scans are taken via the scanner and submitted to the orthodontic company of choice, which then fabricates the aligners and/or bracket placement and returns the orthodontic treatment modality to the dentist.⁷ The accuracy allows for enhanced tooth movement for the most efficient result.

Caries Detection

The detection of caries has become easier with digital diagnostic tools. The assessment of early stages of enamel demineralization can minimize the extent of treatment. Technology going beyond traditional radiography aids in the identification of demineralization.

Caries detection systems include:

• DIAGNOdent by Kavo (kavo.com/en)

• The Canary System by Quantum Dental Technologies (thecanarysystem.com)

• CS 1600 Carestream (carestreamdental.com)

Several digital devices can help detect these demineralized areas in the pit and fissure and interproximal areas of the teeth. Lasers use quantitative light fluorescence or laser-induced fluorescence. When the laser light is aimed at hard tissue, such as the tooth, the light emitted reflects differently on various densities, helping identify demineralized areas. Several diode laser caries detection devices are on the market. Pit-and-fissure lesions are identified by use of specific calibrated reflectance of each tooth by a camera that uses digital imaging fiber-optic transillumination. Basically, it captures zones of demineralization occlusally and interproximally and the images of the illuminated tooth by recording the transmitted visible light.⁸ Some systems even use photo-thermal radiometry as well as laser luminescence to detect decay.^3,5

Occlusal Analysis

When teeth properly function in optimal occlusion, the risk for disharmony such as parafunctional habits decreases. No longer are dentists solely dependent on articulating paper to assess how the dentition occludes.

View more information about the aforementioned companies at:

• Tekscan (Tekscan.com)

• Myotronics (myotronics.com)

There are options available in digital systems that assist in finding the optimal occlusal position. One system measures tactile force management and uses pressure mapping with sensor technology, data acquisition electronics, and processing and analysis software (Tekscan).⁹ Another company, Myotronics, utilizes jaw tracking equipment to acquire scientific data for the diagnosis of complex cases of malocclusion. It helps evaluate the muscles, joints, and nerves involved in the mandibular position and function in addition to the teeth.²

HIPAA-Compliant Email

Just when you are feeling good about using digital data for patient charts and communication, there is another aspect to consider. Are your lines of digital communication HIPAA compliant? HIPAA stands for Health Insurance Portability and Accountability Act of 1996, and the law includes privacy protection regulations that require health-care entities to make efforts to limit the use or disclosure of protected health information to the minimum necessary.¹⁷

HIPAA-compliance is necessary if confidential patient information is communicated by email. Think of it this way: Would you mail your house key in an envelope with your address on it? In terms of email, if you send confidential information over an unprotected email service, hackers may have access to it. Using a secure email service provides encrypting, which protects that email from being intercepted and read by someone other than the intended recipient.

Several companies assist offices in providing a solution to secure email communication between dentists, specialists, and dental laboratories. The systems are simple and convenient, HIPAA compliant, and often free. Utilizing non-HIPAA-compliant services may result in fines.

Some examples of HIPAA-compliant systems are:

• Brightsquid (brightsquid.com)

• OperaDDS (operadds.com)

Computerized Patient Education

Digital patient education is a fast growing area in dentistry. Several systems are on the market that offer educational modalities such as touch screen or voice activation, videos, photos, and treatment scenarios, often within a 3D presentation or animation. The information outlet can be through a computer monitor, television, tablet, or smartphone. Digital presentations help the dental professional effectively communicate with the patient throughout the appointment.

Using such systems helps with informed consent by educating the patient on indicated treatment, treatment options, postoperative-care instructions, dental technology, etc. There are libraries of topics with the systems. Often, the patient can be emailed links to videos on the topics to review at home. Whatever system is chosen, it can be customized to the office needs and communication style and can be offered in a variety of delivery formats such as CD or cloud-based programming.⁸

Some examples of patient education systems include:

• Guru Dental (www.howdoyouguru.com)

• CAESY (caesycloud.com)

• CurveED (curveed.com)

• Consult-Pro (consult-pro.com)

• DDS GP (ddsgp.com)

Diode Lasers

One of the more common and accessible forms of laser technology is the diode laser, which is indicated for soft tissue only. The diode laser can be used for a variety of procedures such as soft-tissue gingivectomy, biopsy, impression troughing, frenectomy, adjunctive periodontal procedures, universal use around restorations, implantology, endodontics, and tooth whitening. The infrared wavelengths of the laser have the ability to precisely and efficiently cut, coagulate, ablate, or vaporize the target tissue.

Examples of dental laser companies include:

• Discus/Philips (philipsoralhealthcare.com/en_us/)

• Biolase (biolase.com)

• Ivoclar Vivadent (ivoclarvivadent.com)

• AMD Lasers (amdlasers.com)

Manufacturers have made the units small, portable, cordless, and low in cost, which make them desirable and easy to add the investment into the practice.¹⁴ Other lasers that are in common use are erbium, Nd:YAG, and CO₂. Of course, state regulations must be reviewed concerning the use of lasers and the participation of the team.

Intraoral Cameras

One of the fun digital technologies is the intraoral camera. The camera is small and fits comfortably in the patient's mouth. An enlarged image of the tooth or smile can be viewed on a computer screen. This is an easy way to illustrate and to communicate what is going on in the patient's mouth, whether it is a fractured tooth, restoration, or periodontal issue.

Examples of intraoral cameras include:

• Carestream CS 1500 Camera (carestreamdental.com)

• DEXcam 4 (dexis.com/io-cameras)

• Gendex GXC-300 (gendex.com)

• Schick USBCam⁴ (schickbysirona.com)

It is a valuable tool for patient education and documentation. Images can be integrated with the practice software to be saved with the patient's information. Some cameras are sophisticated in that they can also help with early detection of caries.^6,12

Digital Photography

Digital photography is a valuable tool to use when communicating with patients, dental laboratories, and potential patients, as well as for use in marketing. Investing in a DSLR camera offers more versatility than a point-and-shoot camera. DSLR stands for digital single lens reflex or digital SLR, and the technology uses a mechanical mirror system and pentaprism to direct light from the lens to an optical viewfinder on the back of the camera. The photographer sees exactly what will be captured. For obtaining crisp photos, it is required to have either a macro lens or a ring flash.

DSLR cameras can be affordable and easy to use by all team members. Photos can be downloaded into the dental practice software or emailed by using a HIPAA-compliant email service. Photos can be used in treatment planning, restorative before-and-after cases, orthodontic cases, head shots, and patient education and documentation.^1,12,16

Examples of digital photography companies include:

• PhotoMed (photomed.net)

• Norman Camera (normancamera.com)

Making the Transition Stress Free

With dentistry evolving and becoming more digitally oriented, it can be overwhelming to implement the best technologies for the dental practice. It is best to assess whether a specific technology will be used on a regular basis in the dental practice and if the return on investment is justified. In the long term, adding or upgrading the dental practice makes processes less stressful and creates more efficient patient workflows.

The key to any technology is adequate training and education of all of those involved in using the technology. Everyone has to be motivated and systems need to be in place. With anything new, there is a learning curve to adapt to the technology. Technology that is properly used according to the manufacturer's directions can provide increased excitement in the field of dentistry.

It is a techy world we live in, and it can be fun, rewarding, and bring happiness to the workday. However, it can also bring stress if the office is not ready to accept digital applications.

Workflows can be streamlined, patient satisfaction increased, and team members more valued as an integral part of the dental office when digital technology is introduced and embraced. A key part of success in implementing digital technology into a dental practice is a properly educated, trained, and willing team. If everyone is on board, and the dentist had done his/her homework on what digital applications and systems are conducive to the success of the practice, productivity and patient satisfaction can increase significantly. RDH

Trish Jones, RDH, BS, is an international speaker and author with experience in esthetic dentistry, dental sales, and working in a dental laboratory. She is a past chair for the American Academy of Cosmetic Dentistry Charitable Foundation Give Back a Smile. She can be reached via email at [email protected]

References

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