Special Delivery

Increasingly, general dentists are broadening their range of services to include that which, traditionally, would have been performed by specialists. For instance, instead of drilling and filling all day long, a clinician might break up the routine with the occasional root canal treatment, implant placement, or minor oral surgery. While the more complex procedures are typically left to oral health specialists, many general dentists receive additional and ongoing training to expand their skill sets to handle the relatively straight­forward cases.

Patients are no doubt thrilled that they don’t have to run all over town to get work done. But because of the additional types of treatments they perform, general dentists are held to the same standards as their counterparts in endodontics, periodontics and oral surgery. Therefore, it makes sense, from the standpoint of liability, efficiency and increased odds for success that they invest in the best equipment they can afford. This is especially the case in regard to imaging technology, which many report as making perhaps the most significant impact in the field of dentistry in terms of accurate diagnostics and treatment.

“If you are going to do things in the specialty world, you need to have the same technology as your specialists,” says Parag Kachalia, DDS, a cosmetic dentist who practices in San Ramon, California, and who also is the vice chair of simulation, technology and research at the University of the Pacific, Arthur A. Dugoni School of Dentistry in San Francisco.

According to hot-off-the-presses forecasting, the compound annual growth rate for dental imaging equipment across the globe is anticipated to grow by 6.8% through 2024. The increase, which appears to be in sync with the growing popularity of computer-aided design/computer-aided manufacturing (CAD/CAM) systems, is attributed to a rise in demand for cosmetic procedures, as well as prosthodontic and endodontic treatments.1

Digital imaging delivers advantages over analog imaging in spades in regard to patient comfort, efficiency, and enhanced image quality. It also helps offices to go paperless — no small thing in light of the Health Insurance Portability and Accountability Act compliance standards. But best of all, this technology — which is available as both intraoral and extraoral radiography — exposes patients to far less radiation than conventional radiography.


VISUAL AIDS

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Not all beneficial visual aids turn out radiographic images. Another visual aid that dentists are coming to rely on is the intraoral camera. The images delivered by these devices are so high quality, that some dentists forego intraoral X-rays in their favor for diagnostics. Many of these camera systems offer still, video and streaming capture. And for patient education and treatment acceptance, there’s nothing like seeing your dental problems blown up on a screen in living color.

“For detailing a problem with a tooth or small area of concern, the intraoral camera gives an instant image that can be seen by both the practitioner and, perhaps more important, the patient,” says Paul Feuerstein, DMD, a Billerica, Massachusetts-based practitioner, who lectures widely on technology in dentistry. “An image of a fractured restoration or tooth on the big computer monitor allows for co-diagnosis and easy acceptance of a treatment plan. For more advanced treatment, a good single lens reflex camera that can show all anterior teeth, a full arch, or a full face showing the patient’s smile is ideal.”

Feuerstein sees this technology as a first line of diagnosis in addition to radiography. But he notes that although these “basic” tech tools are helpful in advancing the treatment planning, newer technologies can bring this to another level.

Aside from the benefits offered by cone beam computed tomography (CBCT), Feuerstein points to digital impressioning as another technology that is hugely relevant, especially due to the prevalence of implant restorations. Says Feuerstein, “Although not essential, a three dimensional impression scan can be used to design the final restoration, crown or bridge and help in directing the placement of the implant. Too many times an implant is placed in a position with no regard for how the abutment or crown will be created. Taking this further, these images can be merged with the CBCT, creating far more accuracy in the planning as well as the manufacture of the surgical guides. The digital impression is also advantageous for the image that is taken in lieu of a traditional impression for accuracy.”

Dental operating microscopes (DOMs) are also becoming a trusted standby for dentists who expand their practices beyond restorative dental work. Especially for working in tiny surgical fields, such as tooth roots, these types of eyewear have become critical. Many practitioners are increasingly seeing the use of DOMs as the standard of care. “If they are going to be doing a lot of complicated endodontic cases, practitioners may want to consider microscopes,” says Parag Kachalia, DDS, a cosmetic dentist who practices in San Ramon, California, and who also is the vice chair of simulation, technology and research at the University of the Pacific, Arthur A. Dugoni School of Dentistry in San Francisco. “Most endodontists today are using microscopes for endodontic therapy and one could argue that this is becoming the standard.”


INTRAORAL RADIOGRAPHY

When it comes to snapping standard bitewings, full-mouth, and periapical X-rays, some dentists still use film-based radiography. This conventional method calls for the use of a darkroom, lots of chemicals, and developing time. It also generates hazardous waste, which requires extra cash outlay for disposal, and doesn’t do the planet any favors.

In contrast, digital radiography is steadily gaining popularity in all types of dental practices, where it is surely becoming the general dentist’s best friend for everyday use. Using sensors instead of film, digital radiography is proving more accurate, lessening the need for retakes; is faster; and is often more comfortable for the patient. It also exposes the patient to less radiation and doesn’t require a darkroom or chemicals, making it a green and cost-efficient alternative.

Digital images can be quickly transmitted to a chairside monitor for instant clinical assessment. Additionally, viewing the digital images onscreen with the patient aids in patient education and treatment acceptance. Images can also be stored electronically, cutting down on the chance that radiographs will become separated from the patient file. In short, digital radiography can enhance diagnostics, streamline workflow, and take practices to a whole new level.

But in order for a dentist to be considered “high tech,” some basic tools are necessary, says Paul Feuerstein, DMD, a practitioner based in Billerica, Massachusetts, who is a well-known dental tech guru. “At this time, digital radiography is a bare-minimum technology necessary for basic diagnosis. The diagnosis is superior to film by the simple fact that the image being looked at is on a large screen, magnified at least 20 times,” Feuerstein explains. “Additionally, there are many software filters that can enhance the image to highlight caries, bone, canals, root fractures and more. For an initial examination of a tooth with a problem, the periapical radiograph and perhaps a panoramic are invaluable.”

EXTRAORAL RADIOGRAPHY

Like intraoral radiography, extraoral radiography such as panoramic imaging may be either film based or digital, and all the same advantages and disadvantages apply. Extraoral radiographic technology is either two-dimensional (2D) or three-dimensional (3D). This typically takes the form of 2D panoramic or cephalometric imaging and 3D cone beam computed tomography (CBCT) imaging.

Cephalometric radiography captures the layout of the entire head, and is most frequently used by orthodontists. Says Kachalia, “If you are doing orthodontics on adolescents you should have a ceph and understand how to treatment plan based on this diagnostic modality.” But most general dentists have at least panoramic technology in their offices. This offers flattened views of the curvature of the mouth, jaws, and teeth for a broad view of the oral cavity and sinuses.

Three-dimensional CBCT radiography has significantly impacted all facets of dentistry. CBCT produces detailed imagery by assembling hundreds of slices of radiographic information and combining it into a 3D view. Diagnostic analyses can then be made through the use of software into which the visual information is imported.

A primary driver of CBCT’s growth is the increased popularity of implant placement, and other kinds of procedures requiring ultra-crisp imaging. But, according to both Kachalia and Feuerstein, in order for general dentists to perform many expanded procedures such as endodontics or implant placement at a high level, CBCT is essential. Says Feuerstein, “A great number of endodontic specialists now have CBCT units in their offices. Without CBCT, there is a lot of educated guessing. At this time, CBCT is essential to treat at the same level as the specialist, as it produces images that are used to find canals, see fractures, locate lesions, and more.” For those customers who say that they cannot afford to buy this technology, Feurestein suggests getting creative, noting, “Cone beam studies are available at local imaging centers, through mobile X-ray services, or even using local specialists to take the images.”

According to Feuerstein, when general practitioners are placing implants, a cone beam image is necessary to ensure the implant will be placed in an area of “good” bone. “The use of 2D radiographs, even with a study model, still risks improper implant placement. Using CBCT also allows the manufacture of a surgical guide, which ensures the proper placement of the implant. Right now, many periodontists are purchasing CBCT units to assist in placing implants. CBCT is a great adjunct when looking at bone levels and bone loss. Also, 3D CBCT images, when shown to patients, make it very clear where bone loss is occurring.”


POINT OF SALE | DIGITAL ADVANTAGE

  • General dentists who expand their practices to include other services may secure a broader patient base than those who do not.
  • Patients appreciate the one-stop-shop concept of going to the same trusted practitioner for all their needs.
  • Digital radiography is poised to claim much of the market share that was at one time dominated by analog radiography.
  • Digital imaging offers countless benefits, from enhanced comfort to lower doses of radiation, to clinicians and their patients.

Feuerstein notes that a number of practitioners feel the use of surgical guides is not essential for the placement of single implants. They believe that it is not cost effective, as it can run them at least $75 to create this guide. “That excuse will soon be gone, as 3D printer costs are plummeting and guides can be made for a couple of dollars in the dental office,” Feuerstein predicts, adding that he thinks that 3D printers capable of surgical guide creation might soon become essential pieces of equipment, with some currently carrying a pricetag of approximately $3,500.

In addition to its usefulness in precision implant placement, Feuerstein points out that CBCT is also of great value in oral surgeries, such as the removal of impacted teeth, and in endodontics. Even treatments for sleep apnea can benefit from the 3D view. “Some practitioners feel that is it necessary to be able to visualize the airway in different positions of the mandible,” says Feuerstein. “This, again, can be done with the CBCT.”

Sales reps should know that CBCT units come in a variety of fields of view, depending on primary use. “An endodontist for example, might only need a small field unit as he or she is looking at only one or two teeth at a time, or perhaps a quadrant,” Feuerstein explains to Mentor. “A dentist who feels he or she will only do one or two implants in a quadrant can also get a unit with a limited field. For more comprehensive treatment, such as for full arch cases, airway and temporomandibular joint disorder (TMJD), a larger field of view is necessary.” Most companies, Feuerstein continues, offer large units in which the field of view can be dialed down — but buyers must understand that CBCT units with small fields of view cannot be turned up. “Buyers must be aware that if they buy a unit that is too small, it might be necessary to take multiple scans in the future if the office increases the areas that are being treated,” Feuerstein shares. While most CBCT units cannot be upgraded, manufacturers often permit unit trade-ins.


LEXICON

Bitewings: A single radiograph showing the crowns of upper and lower posterior teeth in a closed, or biting down, position.
Full-mouth X-ray: Often referred by its shorthand “FMX,” it is a group of radiographic images that shows a patient’s full dentition.
Periapical X-ray: Imaging of teeth from the crown to the tip of the root.
Surgical guide: A template indicating where bone should be drilled for implant placement.
Temporomandibular joint disorder: An issue involving the jaw joint and adjacent facial muscles.


ROAD TO SUCCESS

The benefits of digital systems such as CBCT include enhanced diagnostics; faster, more accurate and more efficient treatment for patients; being able to detect an issue, such as an infection, that may not show up on 2D radiography; and improved patient education and treatment acceptance. With high-resolution, 3D X-rays, it’s possible to see anatomical landmarks such as bone, nerves and sinuses. This comes in handy for all sorts of procedures, allowing easy visualization of everything from fractured roots and canal anomalies, to nerve mapping and identification of periodontal pathologies.

Many of these units are now open platform, which means they can accommodate other branded technologies, such as third-party software. Most accommodate patients of all sizes. Some of these units are upgradable and some offer settings that reduce radiation exposure, in some cases, even lower than 2D radiography. Training is often in­cluded with purchase.

Variations on a theme include units that offer CBCT with the ability to integrate 3D facial photos and 3D scans of analog impressions and stone models into one image. This results in a virtual patient, and helps improve accuracy and boost clinician confidence.

Clinicians will appreciate the convenience of having imaging units that combine 3D, panoramic and cephalometric capabilities. These combination units enable customers to perform a wider range of diagnoses, and facilitate collaboration with other professionals via click-and-send file sharing.

Through the use of high-quality digital radiography and other visual aids, today’s clinicians gain a diagnostic upper hand on diseases of the oral cavity, facilitating early detection of everything from caries to oral cancer. And early, detailed diagnosis is the genesis of minimally invasive dentistry. The upshot? General dentists who expand their practices to deliver specialized treatments, enhanced via the use of state-of-the-art imaging technologies, not only increase clinical efficiency and boost their practices’ bottom lines, but also, in some cases, can save a patient’s life thanks to the crystal-clear imagery. And this makes every CBCT unit quite the special delivery for any practice and the patients it serves.
 

BONUS WEB CONTENT

REFERENCE

  1. Future Market Insights Global & Consulting Pvt Ltd. Dental Imaging Equipment Market: Global Analysis and Opportunity Assessment. Available at: futuremarketinsights.com/reports/dental-imaging-equipment-market. Accessed June 26, 2017.


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From MENTOR. August 2017;8(8): 24-26, 28-29.

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