I still recall the days when it was a big deal to have a digital clock. But today it seems like everything is digitized. Heck, you can even get a digital kitty litter box that cleans itself. And when it comes to dentistry, digital development seems to have shifted into high gear with no signs of slowing down.
According to one report,1 the growth in digital dentistry may be partially due to a growing awareness of the esthetic value of teeth. This is leading to an increased demand for cosmetic treatments, for which patients are more willing than ever to fork out the bucks for digital perfection in the form of highly esthetic prostheses.1
Another factor thought to be contributing to this growth is the proliferation of dental service organizations (DSOs). Such group practices are often better positioned to purchase big-ticket items such as computer-assisted design/computer-assisted manufacturing (CAD/CAM) systems, which can cost more than $60,000.1
CARVE OR PRINT?
But these technologies are not confined to DSOs. For instance, CAD/CAM units, which are used to both design and mill indirect restorations from blocks of material, continue to command space in more practices as prices drop and evidence of the benefits they offer increases. According to one report, starting in 2016, the global dental CAD/CAM market is expected to grow at a rate of about 8%, reaching $3.33 billion by 2027.2
Increasingly, however, another technology is giving the CAM portion of CAD/CAM a run for its money. While CAD/CAM systems create prostheses through subtractive manufacturing, the CAD part of the equation can also be used with additive manufacturing, in the form of three-dimensional (3D) printing, which is used to fabricate an expanding range of dental prostheses and appliances.
Similar to the CAD/CAM market, growth for comparatively affordable 3D printers is expected to continue on an upward trajectory over the next 10 years. By one estimate, it will reach $9.5 billion by 2027 and is poised to some day outpace subtractive manufacturing technologies, especially with the use of metal additive manufacturing.3
When asked what technologies he believes new dentists should consider for their practices, Chicago-based practitioner and well-known speaker on technology in dentistry, William Simon, DMD, replies, “If they have good management in place in the form of a seasoned office manager or even a DSO, then they may be in a position to support a deeper dive into more advanced technologies early. If not, they may need to integrate technologies more gradually. In any case, I feel that digital X-ray, digital panoramic, intraoral cameras and a digital scanner are must haves for any start-up in today’s marketplace.‘‘
Such a strategy makes sense for practices that aren’t ready to spring for CAD/CAM or 3D printer setups. By investing in a digital scanner, a practice can capture impressions that can be sent digitally to the lab, which most likely has those systems.
Point of Sale | Digital Rewards
- Digital technologies are essentially game changers in dentistry, improving, efficiency, accuracy, predictability, and quality of patient care.
- Fabrication technologies such as computer-assisted design/computer-assisted manufacturing systems and three-dimensional printing are becoming increasingly available to dental practices as price points drop.
- Digital radiography, including intraoral and panoramic, and intraoral cameras and scanners are essential to today’s practices.
- Cone beam computed tomography is regarded by many dental professionals as the most significant recent advance in dentistry.
- Scores of digital diagnostic and treatment tools have become available and continue to evolve to support 21st-century dentistry.
At the heart of CAD/CAM and printer systems, is, in fact, digital impressioning, which is performed by digital scanners. This technology offers significant benefits over traditional impressioning. It’s faster and more comfortable for the patient, and because it’s a virtual impression, there are no issues involving disinfection, shrinkage, bubbles, voids, tearing or distortion, therefore accuracy and marginal integrity are improved. And if any portion of a scan is missing, that portion can be easily re-scanned, rather than requiring an entire re-take.
Other benefits offered by digital impressioning include the ability to project impressions onto a monitor to facilitate patient education, diagnostics and treatment planning. In addition, digital files can save space, as they are electronically stored, and eliminate shipping costs as they can be electronically sent to the lab or the in-house CAD/CAM unit or printer.
“Our office is completely digital,‘‘ says Woodstock, New York-based practitioner Michael Tischler, DDS, who specializes in implant placement. “We don’t have charts, but we can handle files more efficiently. Digital impressioning is not only more comfortable for the patient, but a lot more accurate too. It’s the only way to go in my opinion.‘‘
Digital radiography, both intraoral and extraoral, is one of the most significant developments in the technological diagnostic milieu. And its value multiplies exponentially when used in concert with other digital systems. Says Simon, “In my opinion the most significant advances in digital dentistry are digital scanners and cone beam computed tomography (CBCT). These two technologies, even if used independently, elevate the standard of care to new heights. When integrated, they take the provision of dental care to levels that exceed the standard of care.‘‘ He adds, however, that it’s a level of care that most dentists are still not in a position to provide.
But as CBCT, which X-rays dental and facial anatomy in 3D, becomes increasingly accessible to more practices, whether via purchase or use of imaging centers, it’s not uncommon to hear practitioners say they rely heavily on this mini version of the hospital CT unit. Tischler reports daily use of CBCT in conjunction with a scanner and other digital X-ray technologies. Though he says he will take a digital panoramic X-ray in the early diagnostic stages. He notes, “In dentistry, number one is cone beam. It gives you a virtual picture of the patient’s bone and skull. You know what you’ve got so you don’t get surprises. You can also spot anatomical variations, like oral cancers.‘‘
John Highsmith, DDS, who operates a cosmetic practice near Asheville, North Carolina, couldn’t agree more. “Cone beam is hugely important in planning implants,‘‘ he says. “It’s becoming the standard of care. With the accompanying software, you can virtually place an implant into the patient’s skull on the screen, rotate it around, and make sure that the bone is thick enough. On a panoramic X-ray, it may look wonderful, but the bone might be so thin there’s no way an implant would go in that space. With a cone beam, you can tell right away if an implant is going to fit, or if you have to do a bone graft.‘‘
Digital diagnostic tools are not just about image capture. Caries detectors are common fixtures in dental offices and they often double as oral cancer detectors or curing lights with a change of heads. Typically handheld, wandlike devices, they reveal early carious lesions or cracks via transillumination or light fluorescence via lasers or LEDs.
Electric pulp testers and apex locators have become important endodontic aids to test vitality and sensibility, and to measure canal length and establish working length during a root canal treatment.
There are even digital technologies designed to measure occlusion and muscle activity in the jaw. One mentioned by Highsmith offers digital occlusal analysis, using software and a sensor on a USB-based handle. “It’s like digital articulation paper,‘‘ he explains. “You have a little digital wafer in a handpiece that goes in the patient’s mouth. When he or she closes on it, you can watch on a computer screen, in real time, as it shows the force distribution in the mouth when the patientputs his or her teeth together, and what tooth is hitting first, second, third, etc. It’s much more accurate than articulating paper.‘‘
Tischler says he commonly relies on an implant stability meter. Consisting of a probe, power supply, and a peg that attaches to the implant, it assesses the implant stability quotient through resonance frequency analysis, which measures vibration. “It’s a way to measure the stability of the implant and how much bone-to-implant contact there is, so it’s an objective measurement,‘‘ he explains. “It also offers medico/legal protection, and allows you to make clinical decisions based on technology.‘‘
Terms to Learn
Additive manufacturing: Refers to the creation of items through the addition or layering of material such as resins or metals.
Binaural beat: The introduction of closely approximated sound frequencies in either ear results in the auditory illusion of a third sound frequency, or beat. This reportedly leads to an altered state of consciousness.
Subtractive manufacturing: Refers to the creation of items through subtraction or carving of material such as lithium disilicate or zirconia.
Surgical guides: Also called stents, serve as templates to facilitate precise implant placement.
Gaining popularity among practitioners who place implants is computer-guided surgery. This is based on the use of CBCT coupled with software that allows clinicians to basically perform virtual surgery. If desired, a stent, or guide, can be manufactured to help ensure precise implant placement in the actual surgery.
“It’s like playing a video game,‘‘ Tischler says of one system he recently tried. “It takes the information from the mouth and guides you as to where to place the implant. It’s virtual surgery based on a CT plan without a guide. It’s pretty cool, and is one of the most state-of-the-art things right now.‘‘
But image capture isn’t confined to radiography and intraoral snapshots. Highsmith notes, “While intraoral cameras have been around forever, they tend to focus on single-tooth problems. In my opinion, the number-one practice builder and patient-satisfaction tool is digital photography. Show patients photographs of their mouths, and they’ll often say that no one’s ever shown them that before. And that’s just with a digital camera with a ring flash and a good lens. But if you’re taking a picture of the smile or the arch, then you want a more holistic view of the whole mouth. Especially with cosmetics, you’re not looking at one tooth.‘‘
Highsmith adds that digital smile design is also gaining more traction, helping clinicians to select the most appropriate smiles for patients. Comparing digital with traditional methods of fabricating restorations, Highsmith says, “I still believe that having the artistic input of a skilled technician is going to beat a completely digital reconstruction every time. But the lab industry is moving away from that.‘‘
Fear of the needle keeps many patients away from the dentist. But digital dentistry is making inroads into solving this problem. Aside from nitrous oxide, which has long been available to elevate patients into dental office nirvana, a few other technological approaches are surfacing, including one that is said to make injections nearly painless by controlling anesthetic flow rates.
Another approach works through a combination of subsensory microcurrents, neuroacoustic software, an eye mask and dietary supplements that counteract adrenaline. “It’s based on binaural beat technology in which there’s music or sound with a frequency embedded,‘‘ explains John Highsmith, DDS, a cosmetic dentist who operates a practice in Clyde, North Carolina. “So you might have 200 Hz in one ear and 212 Hz in the other ear. It confuses the brain, which senses the difference — 12 Hz — the frequency of alpha brain waves. It’s also the frequency of deep meditation and relaxation. It forces the patient into a meditative, relaxed state.‘‘
Highsmith notes that this technology is relatively new in dentistry, but has been used in other fields such as medicine and sports to reduce anxiety. “It’s definitely a growing thing,‘‘ he says.
TOOLS FOR TREATMENT
For treatment of hard and soft tissues, dentists now have a couple of choices beyond the traditional drill or blade. Many are reaching for ultrasonic- and laser-powered devices. Available in magnetostrictive or piezoelectric formats, ultrasonics are used in a wide range of applications, including scaling, air polishing and surgeries in which bone is required to be cut.
Lasers are another option. Most common for dental applications are erbium yttrium aluminum garnet and neodymium-doped yttrium aluminium garnet, which cut both hard and soft tissues, and diode lasers, which are regarded as soft-tissue lasers. They are said to cut nearly bloodlessly, cauterizing as they go. In fact, many practitioners report that when they use lasers, anesthesia is not necessary.
Curing lights, virtual workhorses of today’s operatory, are commonly LED-based, operating at cooler temperatures than their halogen forerunners. Typically lightweight, handheld instruments, they are sometimes available in cordless iterations and some come with shields to protect operator vision.
Digital technologies as a whole are seen as practice builders, time savers and cost savers. But a shift into the digital fast lane is never without a few bumps. “The challenges to integrating digital technology into private practice are multifarious,‘‘ says Simon. “These include cost, training, maintenance, upgrades, hardware requirements, compatibility, and in some cases obsolescence.‘‘
But there is general agreement among practitioners that the benefits offered by digital technologies outweigh the costs. Says Tischler, “The latest digital technologies allow for better diagnosis and safer treatment. Accuracy, predictability, speed — those are the main things. It’s a technology world, and any dentist who’s not embracing it is really diminishing patient care and safety. It’s like driving a car without airbags.‘‘
And when you’re making the leap into hyperspace on the digital dental fast lane, that’s a risk that’s probably not worth taking.
- Medgadget. Dental CAD/CAM Market 2018 International Top Players Recent Trends, Solid Segmentation, Size, Shares and Forecasts by 2027. February 2018. Available at: medgadget.com/2018/02/dental-cadcam-market-2018-international-top-players-recent-trends-solid-segmentation-size-shares-and-forecasts-by-2027.html. Accessed March 26, 2018.
- Market Research Future. Global Dental CAD/CAM Market Research Report — Forecast to 2017. January 2017. Available at: marketresearchfuture.com/reports/dental-cad-cam-market-1410. Accessed March 26, 2018.
- Griffiths L. Dental 3D printing to reach $9.5 billion by 2027. TCT Magazine. Available at: tctmagazine.com/3d-printing-news/dental-3d-printing-market-grow-9-5-billion-10-years/. Accessed March 26, 2018.
Featured image by WENJIE DONG/E+/GETTY IMAGES PLUS
From MENTOR. May 2018;9(5): 10-14.