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Digital Technology: Dentistry Must Not Overlook the Big Picture
While the influx of digital technology has dramatically impacted dentistry, clinicians have a responsibility to promote safety, efficacy, and efficiency. Maintaining a dynamic approach to oral healthcare whereby patients and dental team members enter a process of co-discovery ensures a thorough diagnosis and treatment plan.
In a recent editorial written by Dr. Harold Slavkin, which appeared in the Journal of the American Dental Association, he discussed the need to revise the scope and practice of the oral health profession.1 His comments addressed whether dental education is meeting the educational needs of young students relative to the impending future of personalized oral healthcare. He suggested that “enormous opportunities have evolved between dentistry, medicine, nursing, and pharmacology along with the appreciation that the mouth is connected to the rest of the body.” He went on to question whether dentistry will remain a learned profession committed to total healthcare or will it become trendy and move away from science as a way of knowing.
It is important to consider Dr. Slavkin’s comments as they pertain to the influx of digital technology, its impact on dentists’ mission of sustainable oral health, and their understanding of oral-systemic relationships. It should be noted that the vision and context of interdisciplinary care, championed in the 1960s by Dr. D. Walter Cohen, the founding editor of the Compendium, is perhaps even more relevant and important today. In the author’s view, today’s interdisciplinary care has moved beyond the classical paradigm of traditional dentistry. When it comes to new developments in imaging systems and planning software as they pertain to implant-related therapy, the dental profession should not just look at what’s new in the way of equipment, technology, and products, but rather must examine the bigger picture.
Undoubtedly, the digital revolution in dentistry has made enormous strides. Electronic patient records, digital dental radiographs, 3-dimensional (3-D) radiography, digital photography, digital impressions, stereolithography, guided implant surgery, immediate prosthesis delivery, and the many iterations of computer-aided design/computer-aided manufacturing (CAD/CAM) applications are just a few of the technologies that appear to be very promising.2 However, it is important that the dental profession guard against “digital intoxication.” Clinicians have a responsibility to promote safety, efficacy, and efficiency (SEE principle). This mantra is a fundamental professional commitment in patient care.
Unfortunately, many of these advances are merely improvements of fundamental technologies that already exist in the analog world. Dentistry is at risk if the profession allows digital intoxication to promote a myopic “tooth-centered” view of oral healthcare. None of the existing or future technologies can circumvent immutable truths of biology and wound healing, dentistry’s gold standard and professional compass. With the continued commercialization of dentistry comes the risk of promoting a future like optometry (perpetuating a myopic view of dentistry).
Adherence to the SEE Principle
If clinicians consider the possibility of a cultural change in dentistry that embraces a dynamic approach to sustainable oral and systemic health, it will enrich the profession and give dentistry a more relevant place in the discussion of patient care and on the bigger stage of personalized healthcare. Emerging science is defining a greater narrative about the relevance of oral health. This begins with the use of information to make decisions from which sustainable oral health can be achieved. However, with the proliferation of in-office cone-beam computed tomography (CBCT) machines (which are largely unregulated), it is timely to pose the integrity question: Is dentistry adhering to the SEE principle?
The dynamic use of CBCT infers interdisciplinary opportunities to manage large amounts of data, which enhances clinicians’ abilities to provide comprehensive assessments and diagnoses for their patients. It is known from observing human evolution, skeletal growth patterns, and recent CBCT studies that the normal modeling and remodeling processes have not been kind to the dentoalveolar complex.3 In general, the human dentition has less than 1 mm of bone on the facial/buccal aspects of teeth based on a recent study evaluating nearly 500 patients from maxillary first premolar to first premolar. This underscores the vulnerability of the periodontium and associated complexities of tooth loss when contemplating implant replacement strategies.4 These dentoalveolar and alveoloskeletal realities have a long-term impact on the outcome of orthodontic treatment and the health of the periodontium. Many adult-related periodontal abnormalities are not seen for decades after orthodontic treatment has been completed. Would meaningful 3-D information about the adolescent patient alter orthodontic diagnosis and treatment planning? Might this lead to risk reduction for patients?
CBCT studies often capture structures that may not be relevant to a particular dental treatment procedure. However, they may identify abnormalities such as pharyngeal space constrictions, vertebral spacing irregularities, sinus pathology, and/or condyle surface area, ramus length, and joint space dimension alterations. The dynamic approach would embrace the inclusion of a maxillofacial radiologist on the team similar to how dentistry’s medical colleagues embrace the review of DICOM data interpretation for their patients requiring imaging. This would provide a platform of cultural similarity between dentistry and medicine. Sleep-related breathing disorders are influenced by cranial-maxillofacial development. Growth and developmental information has the potential to influence interceptive therapies, which might impact the long-term dental and cognitive health of children. Gastroesophageal reflux disease (GERD), enamel erosion, upper airway irritability, and tooth wear all have an impact on sustainable oral health.5 High-resolution pulse oximetry for sleep-disordered breathing screening, glucometer analysis for pre-, post-, and perioperative diabetic monitoring, 3- to 5-lead EKG, capnography, and bluetooth/wireless pre-tracheal stethoscope monitoring for sedated patients are examples of additional digital technologies that can impact patient safety and the future culture of oral healthcare delivery.
A Process of Co-discovery
Perhaps the most important aspect of the dynamic approach to oral healthcare is that the patient and appropriate dental team members enter a process of co-discovery. This implies that all participants handling the patient’s care can share data and have a voice in the diagnosis and treatment plan. This enlarges the discussion to include a broader group of providers and adjunctive contributors.
Co-discovery is defined as a process whereby patients learn about their personalized oral health problems, their patient responsibilities, the role of the dental team in helping the patient achieve sustainable oral health, the potential for correction, treatment options, and the commitment necessary to be successful. In other words, in this scenario the “intoxication of technology” is not driving the decision-making process. As the patient and team become more aware of the problems and potential solutions, treatment benefits and risks can be clarified.
In conclusion, the primary beneficiaries of digital technology are the patient and the team. The ability to communicate visually, whether in person or via Internet conferencing, is an enormous advantage. Communicative efficiency, accountability, and transparency will be enhanced by cloud-based HIPPA-compliant electronic health record (eg, TeamLINKS™, US HealthRecord, Inc., www.teamlinks.com), which can be shared by all team members. The concept of collaborative accountability, the SEE principle, and relevant science will influence the proliferation, consolidation, and integration of digital technologies into platforms that broaden the scope of oral healthcare.6 In the author’s view, 3-D imaging for the exclusive purpose of dental implants, which is currently the most common use, diminishes the prestige and effectiveness of the dental profession.
1. Slavkin HC, Santa Fe Group. Revising the scope of practice for oral health professionals: enter genomics. J Am Dent Assoc. 2014;145(3):228-230.
2. Rosenfeld AL, Mandelaris GA, Tardieu PB. Prosthetically directed implant placement using computer software to ensure precise placement and predictable prosthetic outcomes. Part 1: diagnostics, imaging, and collaborative accountability. Int J Periodontics Restorative Dent. 2006;26(3):215-221.
3. Mandelaris GA, Vence BS, Rosenfeld AL, Forbes DP. A classification system for crestal and radicular dentoalveolar bone phenotypes. Int J Periodontics Restorative Dent. 2013;33(3):289-296.
4. Braut V, Bornstein MM, Belser U, Buser D. Thickness of the anterior maxillary facial bone wall–a retrospective radiographic study using cone beam computed tomography. Int J Periodontics Restorative Dent. 2011;31(2):125-131.
5. Rouse JS. The bruxism triad. Inside Dentistry. 2010;6(5):32-44.
6. Glick M, Meyer DM. Defining oral health: a prerequisite for any health policy. J Am Dent Assoc. 2014;145(6)519-520.
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About the Author
Alan L. Rosenfeld, DDS
Clinical Professor of Periodontics
University of Illinois College of Dentistry
Assistant Professor of Oral and Maxillofacial Surgery
Louisiana State University
New Orleans, Louisiana