Digital Dentistry and the General Practitioner
Embracing and integrating digital tools into general practice
While talk of achieving a digital workflow within the dental practice has become commonplace, clear definitions of what constitutes digital dentistry are still being refined.1 The central components of a dental digital workflow include everything from electronic records and computerized practice management systems to digital imaging systems (eg, 2D radiography and 3D cone-beam computed tomography [CBCT]) and more complex technologies such as intraoral scanners, chairside CAD/CAM milling machines, and in-office rapid fabrication systems.
Although only a minority of general practitioners have wholeheartedly embraced all of these digital tools, the expanding ranks of so-called “super GPs”2 seem likely to further drive the acceptance of digital tools and processes. The benefits these tools and processes offer typically facilitate many of the services that were once provided by specialists but are now increasingly moving into the general dental practice (eg, orthodontics, sleep dentistry, implants).
The Benefits of a Digital Workflow
The advantages of adopting various digital processes are multiple and varied. Don Albensi, Jr, COO of Albensi Dental Laboratories in Irwin, Pennsylvania, points out that by using a digital impression scanner (IOS), “the dentist can use a wand hooked up to one of these scanning units, rather than having a patient potentially gag on impression material while it cures. The IOS has a ‘wow’ factor and promotes a positive patient experience.”
Albensi’s lab has been actively implementing a digital workflow since 2009 to process an increasing number of IOS cases per day. He explains that digitally transferring and importing the IOS file to the laboratory eliminates about 2 days’ worth of processing time because the time to pour up and prepare a model for scanning is eliminated, as is the need for inbound shipping. Any of the inaccuracies inherent to impression material or caused by environmental conditions—such as temperature and humidity—that may create distortion in the stone model are also eliminated.
“With IOS, we also do not have to worry about infectious disease transmission,” he adds. While most dental offices make an effort to decontaminate impressions before shipping, he says that his lab treats every case as if it is contaminated. Lab technicians wear protective gear throughout the unpacking and sterilization process. The impression is sprayed with antiseptics or, if necessary, soaked in them, prior to rinsing—a process that introduces additional moisture and other variables that may create distortion in the model.
Along with the reduced processing time and need for infection control, other overriding benefits of digital impressions are accuracy and the need for fewer retakes, according to Carey Lyons, CEO of Integrated Dental Systems. “That’s why laboratories are pushing their doctors more to go to digital. Some will give digital scanners to their dentists if they send enough cases. They [find that they] go from whatever [their] norm is—say it’s approximately 7% remakes—to less than 1%. If you’re doing thousands of cases and you have 6% fewer remakes, the economics are there.”
Brian Schroder, a general dentist who has been using only digital impression systems in his San Antonio office since 2009, concurs. “When you look at the accuracy, predictability, and consistency, there’s a positive return on investment,” he says. His practice has expanded from using the technology exclusively for restorations on natural teeth to using it for implants and, in many cases, combinations of implant and natural dentition. “We’ve had tremendous success in terms of the accuracy and fit of those restorations,” he reports.
Now, Schroder is combining .stl files from intraoral scans with DICOM data from CBCT scans and merging those files to create surgical guides for implant placement. “Because we know the exact location of the bone and the exact location of the teeth, we can make a surgical guide that allows us to place implants more accurately,” he says, adding that with the better accuracy he can also place those implants more easily and confidently, and restore them more quickly and efficiently.
Back in the laboratory, implementing a digital workflow can also enhance production management, according to Albensi. “In the CAD/CAM department, we have a large amount of cases coming in to be scanned, designed, milled, and printed. With a high volume of units in production, we have a real need to efficiently and effectively manage the workflow to minimize remakes and control production costs.”
Yet another advantage of a digital approach, Albensi points out, is that the people who design cases do not necessarily have to be under the same roof. The lab has one technician who lives in Arizona, and another in New York. Working from home, they both design 50 to 60 units a day in addition to the lab’s five in-house designers. An overseas digital design division does an additional 800 units per night, on average. “What we do not get to complete during the day, we have designed overnight using our anatomical library and preferences, and the units are ready for printing or milling the next morning, ” he says.
Despite these and other advantages, general dentists (unlike dental laboratories) have not been quick to adopt much of this digital technology. Some industry observers estimate that only 5% to 10% of dentists are routinely using IOS to capture impressions.3 Mike Cash, the director of sales and marketing at Glidewell Laboratories, recently reported that Glidewell is seeing 9% of BruxZir crowns and 12.7% of BruxZir bridges being fabricated from digital impressions.3
Depending on what statistical report is referenced, currently only 16% to 18% of dentists are estimated to possess chairside milling capability.4 John Burgess, a professor and dean of clinical research at the University of Alabama School of Dentistry, asserts that 15% to 16% of general dentists in the United States have embraced digital workflows. “It’s growing,” he says. “But that growth has been gradual.”
Challenges to Adoption
“Look at the obstacles,” Burgess urges. “The dentists who can afford new technology are not those who are right out of dental school.” While newly graduated dentists may be eager to use technology, they often shoulder significant educational debt; instead, the dentists who are the most likely to be able to afford new digital tools are older ones with more clinical experience, but may be more reluctant to make the jump to digital dentistry. “Unfortunately, that group of people is less computer-trained. They tend to be afraid of that technology,” he says.
Another challenge is finding a digital impression system that “fits your needs and can be easily used for all your cases,” says San Diego area dentist John Weston, a general practitioner who began embracing digital dentistry 15 years ago. He discovered that while many systems can handle single crowns well, they are not accurate enough for larger cases. “The challenge for the dentist is how do you keep up? What system should you buy? How do you best use it?”
“Any change is disruptive,” Schroder says, adding that moving to a digital workflow requires a lot of change. “Instead of squirting something around a tooth, you shine something on it. Instead of looking directly into the oral cavity, you look at a computer screen. That can be frustrating because it’s different.” He adds, “I’ve never been an early adopter of technology. But I was an absolute believer that if computers could do things for the business side of my practice, then computers belonged in the restorative side of dentistry as well, just like they belong in your purse or your pocket—like your iPhone.”