Inside Dentistry
Jul/Aug 2007
Volume 3, Issue 7

Welcome to the Age of Digital Dentistry

Allison M. DiMatteo, BA, MPS

Welcome to the age of digital dentistry! With the vast array of equipment available for dental applications and the techniques required for their successful use, it’s a time that could be daunting for professionals who are trying to integrate the latest technological resources into their practices. While various clinicians and interviewees alike have commented in Inside Dentistry (See Inside Dentistry Technology Article Index, page 60) that technology and its applications represent additional tools that can be used to provide better treatments, there’s a lot involved in keeping a practice modern and successfully functional. It’s not enough to purchase the latest and greatest of anything.

"Digital dentistry is not a destination as much as it is a journey," believes David Gane, DDS, vice president of digital imaging for Practiceworks Inc, the exclusive maker of Kodak Dental Systems. "You don’t go out and buy a digital dental office."

For one thing, he says, clinicians would never want to spend the amount of money to do so all at once. They also would not be able to train themselves or their staff on how to use all of those technologies simultaneously. "So, it really is a process," Gane says.

From digital radiography to e-scriptions, from computerized case presentations to CAD/CAM restorations fabricated chairside, and from digitally based "surgical guides" and imaging for implant placement to digital impressions, technology is changing the face of dentistry and, in some cases, its clinical outcomes. Consultations and collaborations can be conducted more quickly and perhaps with more detailed and immediate information than ever before. What’s more, such teamwork is not limited by geographic boundaries. As far as the Internet can reach is the breadth of a given practitioner’s referral network.

The costs to incorporate technology may seem luxurious at first, but what’s a high-end advancement today may well be considered the expected standard of care tomorrow. A cautious willingness to embrace new technology can help dental practices in their quest for success. According to Roger Levin, DDS, chief executive officer of Levin Group, Inc, there are three key reasons for incorporating a technology—digital included—into the practice.

The first is improved quality of care; the second, enhanced efficiency and speed; and the third, realizing a return on the investment as a result of its incorporation. Levin says you don’t necessarily have to have all three in order to find a technology worthy of integration into the practice, but you do want to have at least one.

"We are entering an era in dentistry where professionals simply cannot afford all of the technologies that are available," Levin explains. "Based on that, we are in a situation whereby practices could face a crunch if they over-invest and do not realize a return on some technologies, thereby experiencing a negative financial result."

Chances are, if you’re considering new digital technology for your practice, it’s because you’ve been motivated to do so based on the promise of realizing at least one of the criteria Levin outlines. If you’re not interested, then the costs of the technology—or fear of incorporating and using it—could be holding you back. In either case, our experts agree that it’s important to consider any technology in the context of your specific practice and how you’ll use it before making a "yea" or "nay" decision.

"A practice with poor management or poor operational systems is going to have a lesser result from a technology," Levin explains. "Practices should have their systems in place and then identify where the technology fits, how it will be used, who will use it, whether its use will be a reimbursable service, etc. All of these questions should be answered before integrating the technology."

This month, Inside Dentistry helps to define what is meant by "digital dentistry" in terms of the technologies that are now being implemented in today’s practices. Governing some of them and how they’re used are different regulations designed to safeguard patients and professionals alike; we review some of the organizations responsible for those guidelines. Overall, the facts unfold to usher in the age of digital dentistry—a time when technology now is making the previously unimaginable possible (eg, earlier screenings and diagnosis of "invisible" conditions; instantaneous collaboration with someone around the world) and enhancing the efficiency with which improved clinical outcomes are realized.

Defining Digital Dentistry and Its Benefits
Claudio Levato, DDS, a private practitioner and frequent author on topics related to digital dental technology, defines the digital dental practice as one that uses technology and incorporates digital applications almost exclusively. Therefore, the practice would avail itself of computerized radiographs, a computerized database, and an ability to scan all documents to create digital records, among other capabilities.

To Margaret Scarlett, DMD, president of Scarlett Consulting International, the digital dental practice is one in which all of the information beyond dental records and practice management functions—such as insurance information, radiographs, digital billing, CAD/CAM systems, digital impressions, etc—are fully integrated into one universal system that’s accessible by everyone in the practice. "That’s how I conceptualize it," Scarlett explains. "I don’t think there’s actually anything that does all of that, although there are some systems that offer more of an all-in-one concept for a digital practice than others."

The digital dental practice and what digital dentistry entails can mean different things to different people, says Gane. "The digital practice really is a dental practice that deploys and leverages digital technologies to enhance patient care, as well as the bottom line of their business," he elaborates. "When most people think of a digital practice, they think of the most common digital modality that’s being adopted in the market, and that’s digital radiography, but it’s certainly not limited to that."

He explains that there are a number of other technologies that provide digital information to the practice, including—but not limited to—digital cameras, intraoral cameras, tooth colorimetry devices, and caries detection units. The digital technology that’s most often overlooked but is the most obvious, Gane says, is the practice management software system which, usually through data entry or some other input device, is probably the biggest source of digital information in the practice.

When the right combination of technology is thoughtfully and strategically placed in the dental practice, it can enhance the office’s performance, as well as the level of care it provides. According to Levin, technology does one of two things. It either replaces an existing function at possibly a more efficient level, or it brings in a new function. Either way, he says, clinicians need to consider the technology as a tool, one of a series of steps in any practice system.

Muralidhar Mupparapu, DMD, MDS, director of oral and maxillofacial radiology at New Jersey Dental School, says that digital technology enables the delivery of cutting-edge care to patients and promotes administrative conveniences (eg, radiographs can be used for instant consultations; office won’t require much space for storing records or charts). Other benefits that can be realized include the following:

"Digital technology really provides very easy access to records no matter where you are in the office, and it can be accessed from multiple points," Scarlett explains. "For example, where I’ve seen it work successfully in dental practices is where the front desk staff may have access to information for updating the medical history form, while the person in the back room—who may be dealing with billing issues—also has access to the billing records."

Essentially there doesn’t have to be a physical transmittal of the chart—including treatment room information such as digital radiographs—so multiple people can access the same record within an office at the same time. That, Scarlett says, is really a fabulous digital capability.

Better Diagnoses and Patient Education.
Paul Feuerstein, DMD, a general practitioner from North Billerica, Massachusetts, who writes about dental technology, remarks that using digital technologies in the dental practice has enabled earlier and better detection of diseases in the oral cavity. "All of a sudden you can find dental disease—periodontal disease or caries—very early on and treat it right away in order to prevent major trauma to the patient," he says.

To V. Kim Kutsch, DMD, a private practitioner from Albany, Oregon, who also has authored numerous articles about technology in the dental practice, a significant consequence of applying digital technology to dental care is how it enables clinicians to provide a better diagnosis and message to patients about the condition of their oral health. For example, he says that using a 19" monitor and intraoral images of their teeth allows him to diagnose oral conditions much better from when the images are enlarged (eg, better identify decay or other conditions at earlier stages) as compared to the small, standard size 2 emulsion film. Simultaneously, such enlarged details enable him to better communicate with the patient about the actual condition of their mouth and teeth, Kutsch says.

"The more patients understand and the more information they have, the better decisions they are going to make for themselves," Kutsch explains.

What’s more, although dentists he’s spoken to may be drawn to digital technology based on time-savings, if you asked them if they feel they can do a better job diagnosing and treating cases, they overwhelmingly say "yes," Gane admits. "Dentists are able to diagnose more quickly and efficiently, both quantitatively and qualitatively," he adds.

Virtual Colleagues and Collaboration.
With the advent of digital records and radiographs, consultations and second opinions are just an e-mail away. According to Kutsch, the digital age has really changed dental practices from the standpoint that once upon a time, solo practitioners did in fact work solo. They really had to depend on their own skills, he says.

Today, even if they’re in practice by themselves, there’s a digital connection to the US National Library of Medicine (http://www.gateway.nlm.nih.gov/gw/Cmd), as well as to the vast network of experts and colleagues from anywhere in the world. For example, he admits that on a daily basis—in accordance with HIPAA—Kutsch shares cases with fellow members of the two different study clubs to which he belongs, so everyone is learning from each other.

"In that regard, digital technology in the dental practice has increased our communication among practitioners, and that has to benefit dentistry," Kutsch says. "I think long term we are all learning more from each other from the amount of cases everybody sees."

Then and Now
Looking back 10 years to when, for example, digital radiography was coming into its own, there were many obstacles to that technology’s integration. According to Mupparapu, there weren’t computers with the speeds available today. There weren’t USB connectors.

"We did the work with what we had, so things were slow, and acquisition of the digital radiograph would be a little cumbersome," Mupparapu admits. "So, it was definitely harder back then for someone to imagine the need to jump on the bandwagon and come over to digital because there were obstructions in terms of the technology itself."

Today, Mupparapu points to high-speed connections and wireless acquisitions as advancements that have made it much easier to convince someone to come over to digital technology than in years past. Networking the computers in a dental office enhances everyone’s ability to access imaging and treatment planning tools.a When the network is wireless and complies with HIPAA regulations and security protocols, access and integration is further enhanced, saving valuable chairside time and increasing productivity.b

What’s more, the breadth of technology and the scope of diagnostic/treatment planning possibilities are also enticing. Digital technologies such as Cone Beam CT (computerized tomography) are allowing dental clinicians to view the patient’s anatomy in three dimensions very quickly. Implant surgical guides can be fabricated based on radiographic information prior to surgery for more accurate placement. In fact, the development of precise presurgical imaging techniques and surgical templates is enabling dentists to place implants with greater ease and predictability.c

According to Feuerstein, the in-office CT units enable dental practitioners, for example, to scan a patient’s jaws to begin examining developmental issues or previously "invisible" pathology. If dentists are going to perform orthodontics, surgery, or place implants, they can now start to see where teeth are, where nerves are, and where sinuses are, he explains.

"It’s an unbelievable tool that we’ve never had available to us before in dentistry," Feuerstein says. "Now we can see exactly what we can do without having to wonder "what if..." Now we can see exactly what we’re doing, where we’re going, and what things are going to happen."

Despite the more ready ability to add a CT scan unit to the dental office, the technology isn’t for everyone, Feuerstein says. But, for those who are interested, there are a variety of units from different manufacturers available.

The Challenges and Disruptions
Despite exciting advancements and enhancements to technologies that can be used in the clinical and administrative aspects of the dental practice, challenges to their use and obstacles to adoption remain.

When deciding how to integrate different types of digital technologies into the practice, the greatest challenge is interoperability of the systems or general records, explains Scarlett. She says that the majority of dental record systems are primarily for practice (patient) management and supply ordering, as well as charting. Other technological or digital tasks conducted in the dental office, such as digital radiography, CAD/CAM, digital billing or digital receipts for checks, are all possible, "but the interoperability is by and large pretty limited," Scarlett says.

"Probably the most integrated system is a VistA-based system from the Veteran’s Administration Hospital, which is not to be confused with the Microsoft operating system Vista," Scarlett explains. "They have a dental component that’s integrated with complete medical records in a seamless system, with storage for laboratory testing and billing functions, as well as the dental charting and medical history."

Just as she’s seen digital technology in the dental practice afford users tremendous success, so too has she seen the operational difficulties. "Where I’ve seen digital technology not work in the dental office relates to interoperability and the use of a particular system," Scarlett explains. "For instance, if they’re using a digital system for payment transactions that doesn’t integrate with the digital system for record keeping, then office staff will be required to physically input the information from one system to another, and that’s where mistakes are made."

Kutsch says that most of the dental technology companies today use an open platform so that different technologies can interface (ie, work together) and be upgradeable. Many are Windows based, which he says makes it easier to add or upgrade different technologies (eg, CAD/ CAM restoration systems).

In addition to evaluating what is an appropriate expenditure, it is equally important to select the best payment method. According to Levin, there are wonderful technologies that are very expensive for a practice. If they’re leased or loans can be taken out to pay for them, the practice could see a very positive return on investment in a short period of time. In other words, if it’s leased and then used and the practice production and profit from it are continually higher than the lease payment, then that’s a positive return on the investment.

But Levin cautions that technology does become obsolete, and that obsolescence factors into cost. Will you be able to upgrade the technology, or will it need to be discarded completely? If you assume a long-term lease or loan, will you still be paying for the original technology investment after it’s no longer in service? Therefore, Levin says it’s also important to examine the time frame for return on investment.

However, proponents of digital technology in the dental practice assert that some purchases just have to be made. "You just have to go ahead and consider the purchase like any other piece of equipment that’s going to wear out or become obsolete over time," Kutsch says. "You need to get value from it during the period of time you are using it."

And when you’re talking about certain digital technologies, the life expectancy you’re likely comparing will be apples to oranges. For example, Kutsch says the life expectancy of a computer system is 5 years, whereas the traditional dental chair will be 40 years. "Yes, there’s a shorter benefit from using that technology, but your option isn’t to not have any technology at all," Kutsch explains.

Feuerstein explains the adoption of technology in relation to its cost by remembering the days when color televisions were first introduced. They were very expensive, but people paid what they paid for them. "They wanted it because it was available to have it," he explains. "You go into digital dental technology when you’re ready to use it, so you’re going to pay a premium when it first comes out. But if it’s something that you’re ready to use, you get the benefit of working with it and using it right away."

Levato suggests that while cost may be a factor of why dentists are reluctant to invest in technologies, he says too that confusion regarding what exactly is required (and hence, what things will really cost) also holds them back. "A dentist doesn’t mind spending the money if he knows what he’s getting," Levato believes. "But the reality is that there are so many hidden costs—wires, backup systems, bridging software, etc—that dentists are never really fully aware of the actual costs until they’ve jumped in, and then sometimes it’s too late to jump back out."

What’s more, it’s not always easy to shop and compare because different vendors will tell you different things, he says. As a result, it’s difficult to develop a clear idea of what the real cost is to fully integrate a given technology.

Unwillingness to Adopt and Adapt.
If practices—not just dentists, but their hygienists and assistants—aren’t ready for technology, then they should be careful when making technology investments, says Titus K. Schleyer, DMD, PhD, associate professor and director of the Center for Dental Informatics at the University of Pittsburgh School of Dental Medicine.

"If they are very conservative and not very motivated to try new things or adopt new technology, then clearly the dentist will have an uphill battle to get the technology working in the practice," he explains. "The practice has to be ready mentally and operationally for the new technology."

Unfortunately, Levato observes that many dental professionals approach technology with fear and trepidation. They don’t really want to be there, but they feel they have no choice, he says.

"A lot of early adopters of digital dental technology saw it as an opportunity and a challenge, but they wanted to go ahead and put all of their patient information into a format that would allow them to be better able to multitask," Levato said. "In other words, they wanted everyone in the office to be able to have ready access to all the administrative and clinical information simultaneously."

The Standards For Technology, Care, and Administration
Gane comments that there are many private and government agencies that control, regulate, and provide guidance to the dental profession about how different digital technologies and medical devices should be used. Among them are the US Department of Labor Occupational Safety and Health Administration (OSHA), the US Food and Drug Administration (FDA), the American Dental Association (ADA), the National Council on Radiation Protection & Measurements (NCRP) (www.ncrponline.org), and Digital Imaging and Communications in Medicine (DICOMsm) (http://www.DICOM.nema.org). Their independent and collective efforts help to ensure the safety and health of dental practice employees and patients; they set standards, provide training and education, and encourage overall improvements when necessary, Gane explains.

Gaining in significance to the dental industry—especially since the ADA has endorsed it and educated its membership about it—is the DICOM standard, Gane says. DICOM is a global information technology standard that is used in virtually all hospitals worldwide to ensure the interoperability of systems used to produce, display, send, store, process, retrieve, query, or print medical images and/or related documents. "The ADA endorses DICOM, and that’s had huge implications in the digital dental office of the present and future," Gane explains.

According to Levato, the DICOM standard has been a work in progress for a few years and it is not mandated by law. However, as demonstrated by the fact that the ADA is working on DICOM, there are attempts by organized dentistry to issue guidelines so that the manner in which digital information is stored and transferred has a standardized format. "We’re not quite there yet," Levato admits.

The Health Insurance Portability and Accountability Act (HIPAA) of 1996 is the federal legislation that’s guiding many issues surrounding the privacy of dental records and who has access to them and authorization to disclose/refer the information. HIPAA brings to the forefront again the challenge of interoperability, Scarlett says, particularly in terms of ensuring that electronic records can be securely transmitted from a general practice to a specialty practice (eg, periodontist or oral surgeon) while maintaining the patient’s privacy. "Of course, the patient will have to authorize that transaction, but this is an example that really articulates the case for national privacy standards for dental records," Scarlett believes.

When discussing dental radiography, then it’s Report #145 from the NCRP that dictates the guidelines for dental healthcare providers regarding radiation dose limits for occupational and nonoccupational exposure. It also governs radiation protection guidelines for operators, patients, and the public.d In a nutshell, they provide radiography guidelines and other guidance designed to protect the public against the non-judicious use of ionizing radiation, Gane says.


Mupparapu says it best. The practitioner with technology will be a flourishing practitioner more so than somebody who doesn’t want to use technology, in his opinion. He elaborates that the dental practitioner who is sophisticated technologically will attract more patients, and the patients will be there for the benefit of the profession.

"A patient would rather go to a dentist who is technologically savvy than someone who is old fashioned," Mupparapu says. "Today’s patients actually embrace technology much more than the older generation. They are very well-informed overall."

But staying abreast of technology requires a certain level of dedication and commitment to the education and information process, Feuerstein suggests. Therefore, he encourages dentists to continue reading professional journals and magazines, as well as attend continuing education meetings, in order to stay informed about what’s happening with dental technology.

"If you’re just sitting back and staying with what you learned to use in dental school, you’re going to be far behind the profession, and you’re doing your patients a disservice," Feuerstein says. "It’s such a dynamic technological time in the profession right now that dentists really have to stay abreast of these things."

So yes, stay abreast of what’s new, but be a little bit discriminating about the statements made about technological innovations and/or specific brands, cautions Schleyer. Rather than rely on vendors, he suggests reviewing objective data.

"I would try to stay as up-to-date about technological developments as possible while differentiating the wheat from the chaff," Schleyer says. "Discriminating judgment is warranted so that dentists won’t fall for every fad that the marketplace is in favor of at the time."

d Mupparapu M. Radiation protection guidelines for the practicing orthodontist. Am J Orthod Dentofacial Orthop. 2005;128(2):168-72.


Assigning an Order to the Integration

Whatever technology dentists acquire should really fit with the kind of vision they have for their practice and what they want to do well in it, explains Titus K. Schleyer, DMD, PhD, an associate professor and director of the Center for Dental Informatics at the University of Pittsburgh School of Dental Medicine. If the practice is primarily restorative, then perhaps technologies to consider integrating are those that relate to the fabrication of crown-and-bridge restorations (eg, CAD/CAM milling technology or digital impression systems). Selecting the appropriate technology to meet specific objectives is among the keys to integration success.

"Any technology has the potential to disrupt the practice workflow," Schleyer says. "The challenge for dental practitioners is to figure out how to implement the technology while not losing too much efficiency and effectiveness in the short term, and realizing the gains that they expect in the long term."

For this reason, Claudio Levato, DDS, a private practitioner who has authored numerous articles about the integration of digital technology into dental practice, emphasizes that moving toward the truly digital practice doesn’t have to happen all at once. Echoing the statements of others, the move is a journey, and it’s one that requires a master plan outlining what should be incorporated each step of the way, he says.1 This plan will address such things as whether or not the current office location and space requirements are adequate; whether any existing equipment can continue to be used or must be discarded; and whether or not technology must be retrofitted to work with existing facilities.1 With each step, the respective component is introduced to the practice and the staff so that they can become confident with it before adding and moving on to the next one, Levato explains.

"As the staff learns to work with it, they’ll become more excited, and they’ll help push you to the next step," Levato has observed. "Really, incorporating digital technology is something that involves the whole team, but it can be done gradually and over time."

As you prepare to invest in digital technology for your practice, keep in mind that there are two types: administrative and clinical. In the administrative case, clinicians will want to have the best technology they can purchase that provides the highest levels of efficiency, speed, and time savings. Ultimately, each of those will create a return on the investment, says Roger Levin, DDS. In terms of clinical technology, what type to purchase—again—goes to heart of what type of dentistry is being practiced in that office.

Below are just a few of the digitally based technologies that can be added to the dental practice over time; there are many others that—depending upon the practice—could also be incorporated, such as specialized CAD/ CAM equipment, sophisticated radiography devices, and others. The order in which they are listed represents suggestions for the chronological order in which to incorporate them into the dental practice. However, every practice’s needs and capabilities are unique; select your digital technology purchases and integration timetable based on your individual practice plan.

1. Computers and monitors in every operatory.
Considered by many to be the backbone of any digital integration, a good hardware/software platform in the practice that consists of workstations and monitors in every operatory "is the first place to really start so that the entire office can go digital," explains V. Kim Kutsch, DMD, a private practitioner who routinely authors articles about technology in the dental practice. He also recommends two monitors and workstations in each operatory so that while the doctor is using one to image the patient, the assistant can use the other to update patient records, take notes, etc.

"If you don’t have computers in the treatment room, then all of the technologies that you buy aren’t going to be worth working with," explains Paul Feuerstein, DMD, also a general dental practitioner who has written extensively on technology in the dental practice. "That’s the backbone and the largest investment of the whole process."

Then, after purchasing the computers, do some thinking and some planning, Feuerstein says. Where are you going to put the computers? Where are you going to position the monitors? Thinking forward, he asks, what are you going to use the computers for? For example, if the computer monitor will be used to view intraoral camera images that detail tooth decay and you want to use those images for patient education and to encourage treatment acceptance, then you need a monitor in front of the patient. You may also need a monitor behind the patient so that practice management tasks can be completed, he suggests.

In this regard, integration of not only computers—but also other components of the digital practice—is significant to the efficient and effective functioning of the dental office.2 This might involve the placement of digital imaging tools in or close to the delivery tray and the use of strategically and conveniently placed foot pedals for use with intraoral imaging devices, as examples.2 Equally important to integration and ease of operation are the networking and interconnectivity of assorted digital devices.3 For example, the office and practice space should be planned to accommodate wiring below floors, above ceilings, and perhaps within walls.3

Schleyer has found in his research that dentists he surveyed liked having computers chairside. Chairside computers were considered beneficial not only for the patient education functions it enables, but also for the immediate administrative tasks that could be accomplished while the patient is still in the chair, such as providing statements and/or scheduling follow-up appointments.

"If you think about a traditional practice, the patient gets up, goes to the front desk, and waits to get their next appointment scheduled," Schleyer says. "Efficiency from chairside computers is clearly one aspect that can improve the care and flow within a practice."

Additionally, with the computer infrastructure in place, it becomes easy to then add more digital devices, Schleyer comments. Clinicians can add an intraoral camera, for example, and then not do anything new technologically for a year or two. When they’re ready, they could add a digital camera for extraoral photography, but because the computers are already set up, dentists can do it at their own pace, he says.

2. Patient/practice management software.
According to Muralidhar Mupparapu, DMD, MDS, a frequent researcher and author of digital technology integration, patient record or practice management software forms the basis for future digital conversions. Without it, integration of other technologies in the practice would be very difficult, if not impossible, he says.

The computer integrates both administrative and clinical patient data, including billing information, digital photographs, digital radiographs, and e-scriptions all in one bundle, Mupparapu says. It’s possible for the dentist and office staff to view all the information under "one umbrella" for patient care. "In fact, it’s now possible to even remotely access the data using various Internet tunneling protocol (ITP) that are secure, or even via the Internet using high-speed connections," he observes.

Levin says that a dental office today without practice management software is archaic, the job of managing records is too hard, and the ability to obtain information and data becomes too difficult. "Even though a practice can function and survive without practice management software, it is a very inefficient and less effective method," he observes.

Once a program is in place that will allow dentists to combine administrative tasks and clinical tasks, then dentists can begin to incorporate the digital applications that they want to use, says Levato. He suggests that any intraoral camera may be a good place to start, since these can be incorporated into virtually any practice management system that has an imaging component.

3. Digital radiography.
"I think the most important digital technology out there for the standard general practice is digital radiography," Kutsch says.

According to Mupparapu, himself a radiologist, digital radiography acquisition is dose-sparing, so less radiation is used. Also, he notes that integration of the digital radiography software with the practice’s patient record/management software is now an easy process.

"I’m a radiologist, so obviously I’m a little biased, but I would say digital radiography is definitely a technology that nobody should be without," Mupparapu believes. "It’s now easy to convert to digital radiography and eliminate many of the problems that offices face associated with film processing, duplication, long-term storage, insurance, etc. In fact, digital radiographs can be archived, shared, and used for immediate long-distance consults without having to be duplicated manually for "snail mail" consultations."

3. A Scanner with transparency adapter.
Levato notes that for clinicians who truly want to be digital, another necessary component is a scanner with a transparency adapter. This will allow clinicians to scan X-rays that are mailed to them so that they can be added into a patient’s digital record. What’s more, it’s also used to convert paper records into digital files so that they, too, can become part of the practice management program.

4. Intraoral cameras.
"I think that no practice should be without intraoral cameras, and certainly those are digital today as well," Kutsch says. "It is very important for clinicians to be able to show patients their condition and help educate them so that they can make better healthcare decisions for themselves." Therefore, in this regard, intraoral cameras are a must.

Although some people think intraoral cameras might be redundant to a regular digital camera (see below), Feuerstein says both are needed. And while intraoral cameras used to be big, clumsy monstrosities, today they’re about the size of an electric toothbrush, less expensive, and easy to use, he says. They can be directly connected to the operatory computer via the USB port, so dental clinicians can instantly provide patients with a photographic explanation of the inside of their mouth and the conditions affecting their teeth (eg, tooth fractures, gingival recession).

5. Digital camera (regular).
Feuerstein advocates incorporating a nice digital camera—nothing fancy, spectacular, or expensive—but something with a few mirrors and retractors. With a basic knowledge of how to take photographs of your patients’ teeth, you’ll have the foundation for showing a new patient what your practice can do with a "show and tell." The camera can also be useful for treatment planning by enabling a patient to see what condition they have, what they need, and what you can do to treat them.

6. Caries detection device.
At the earliest possible signs (eg, a small spot or catch on a tooth), a caries detection unit can help clinicians determine if there’s decay or just a small scratch on the enamel surface. And, according to Feuerstein, it’s a must-have piece of digital equipment that eliminates the "wait and see" approach to potential restorative problems.

"For years we were taught that if a patient presents and during the exam you notice a little notch in their tooth, you watch it and if it gets big enough, then you place a filling," Feuerstein recalls. "Now you can look at that little notch or scratch and determine if it’s early decay before it becomes giant decay."

7. Digital impression system.
Among the emerging digital technologies slowly being adopted by dental practices is digital impression taking, says Levin. Similar to other digital technologies like radiography, digital impression systems create an electronic "impression" that is forwarded to the laboratory, thereby eliminating all of the traditional physical components of an impression, he says. Because these digital scans (impressions) can be viewed immediately on screen, clinicians are afforded the opportunity to make adjustments to preparation margins, if necessary, and otherwise ensure that they’ll be providing their laboratory with accurate and sufficient information.

As far as selecting from among specific brands of different types of technology, Schleyer acknowledges that dentists take a more-or-less large leap of faith when they buy digital products. Talking with colleagues and seeing how they’ve faired with certain equipment can help in determining how long it will take to break even on their purchase/investment. It may also be possible to "pilot test" the technology in the practice to see how well it will work. If it increases efficiency, profitability, and/or improves treatment outcomes, than the decision to invest in the technology is easier.

What to stay away from? Schleyer cautions against purchasing very new products because these typically are sold without having been tested adequately, as exemplified by consumer computer software being field-tested in the real world (ie, actual early users experience and discover the most significant problems and errors). "I would put immature or very new technology products in the category of what not to purchase," Schleyer says. "It’s better to wait until the bugs have been worked out."

1 Levato CM. Putting technology in place successfully. J Am Dent Assoc. 2004; 135(Suppl):30S-37S.

2 Schleyer TK.Why integration is key for dental office technology. J Am Dent Assoc. 2004;135 (Suppl):4S-9S.

3 Unthank M. Designing your office for technology. J Am Dent Assoc. 2004;135 (Suppl):24S-29S.


Questions to Evaluate Whether a Technology Fits the Practice

In the July/August 2006 issue of Inside Dentistry, Roger Levin, DDS, provided readers with a list of eight questions to ask themselves before embarking on a new technology purchase. This year, we asked Dr. Levin to revisit those questions and help us weigh their usefulness for all potential digital technologies that a practice might consider purchasing.

  1. Will the technology improve the quality of patient care?
  2. Will the technology increase efficiency?
  3. Will the technology reduce costs?
  4. Will the technology generate new revenue?
  5. Will the technology improve safety?
  6. Is the technology easy to use?
  7. Will the technology provide a return on investment?
  8. Can the technology be integrated with current practice technologies?

The questions are as valid today as they were then, regardless of whether the technology is related to hygiene, restorative, administration, or accounting, Levin says. Practices don’t need a "yes" answer to all eight questions. What they do need is to analyze the questions and then gauge the odds that the technology they’re evaluating will be beneficial.

For example, there may be a technology that doesn’t improve patient care, but it does reduce operating costs while maintaining the quality of patient care. That technology should be explored, Levin says.

There may be a technology that doesn’t necessarily increase efficiency, but it generates new revenue. In fact, the technology might be less efficient if it’s related to a new service that’s being offered for the first time.

But before even asking these questions, Levin emphasizes the need for practices to have a technology plan that spans 3, 5, or 7 years in terms of bringing technology into the practice. It’s impractical to expect to purchase everything all at once. The danger is that if dentists buy too much too fast, they might not be able to handle it financially.

In order to develop that technology plan, the practice should identify its needs, Levin says. If the practice is a restorative practice, it may want one set of technologies. If it is an oral surgery practice, it may want another set of technologies, such as those that are implant-related or among the newer radiographic technologies.

Certainly, he says, there are technologies that practices shouldn’t purchase—not because they’re inherently bad, but because they just don’t fit every practice. That’s why Levin believes it’s important for dentists to identify their core area of services and what types of technologies will make a positive difference in how they practice and/or manage their business.

"The biggest reason not to buy technologies is if they do not fit any of the three criteria (eg, improves quality of care; increases efficiency or speed; provides a return on investments)," Levin says.

Once a technology is selected, Levin advocates conducting a 90-day study during which time the technology is actually used in the office and evaluated. How many patients is it used for? How efficient has it been to use? If it’s clinical in nature, has it enhanced case acceptance and/or clinical outcomes (ie, revenue/patient care)? This type of study will quickly tell a dentist whether or not the technology makes sense in the context of his or her practice environment, Levin advises.


Training the Technology

You’ve made your purchases. You’ve installed them into the practice. Now, how do you use them and actually integrate them into the day-to-day practice operations?

According to Claudio Levato, DDS, a private practitioner and dental technology observer, training is something that should be conducted practice-wide on an ongoing basis. While you may spend 2 or 3 days initially with a trainer to learn a particular product, he or she will eventually leave; you’ll have forgotten about 70% to 80% of what you heard. So, once you’ve started working with the product, Levato says it will be important to bring the trainer back in. And staff must be involved in the training process.

"A major deficit we see is that dental offices invest in technologies but don’t sufficiently train their staff in how to use it," observes Roger Levin, DDS. "Yes, some technologies are changing so rapidly that it’s hard to keep up with training, but if it’s a positive technology for the practice, training the staff thoroughly will yield the best results. Everybody will be more efficient and the technology will be used in a far more effective manner."

What’s more, Levato comments that the initial training received in how to use a respective product is just that: initial training. Therefore, it’s important for clinicians and staff to be willing to step out and participate in courses that are designed to help them use their digital applications more effectively. These may be provided by:

• product manufacturers;
• vendors;
• organized dental meetings; and
• dental schools.

In addition, whenever the technology vendor introduces a software upgrade that’s fairly substantial—and most major software companies and practice management system companies do this annually or about every 18 months—then Levato recommends at least a full day of training for the dentist and staff. This is an opportunity to learn the new applications and review the old ones, he says.

Digital Dignitaries

Digital technology can revolutionize dental practice, but even the most technologically savvy dentists occasionally needs advice or an opinion to help them formulate a strategy for implementing digital technology into their practice. Inside Dentistry is pleased to offer a list of some of the recognized thought leaders and notable figures in the realm of digital practice. They welcome any questions or dialogue regarding the digital age of dentistry, and can be reached via the methods listed below.

Eugene L. Antenucci, DDS
Huntington Bay Dental
222 East Main Street
Huntington, NY 11743
Paul Feuerstein
78 Treble Cove Road
North Billerica, MA 18162

Joel Benk, DDS
620 Peachtree St, Suite 204
Atlanta, GA 30308
Eliezer Ganon
Think Tank

Allan G. Farman, DDS
University of Louisville School of Dentistry
501 South Preston
Louisville, KY 40202
Claudio M. Levato, DDS
Comprehensive Dentistry, Ltd.
183 S. Bloomingdale Rd, Suite 200
Bloomindale, IL 60108

Alex Touchstone, DDS
Touchstone Dentistry
4835 Sirona Drive, Suite 300
Charlotte, NC 28273

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