Garnering Patient Buy-In through Visual Communication
Imaging technologies enhance education
Parag R. Kachalia, DDS
The days when patients followed their doctor’s instructions without question are fading away. Today, patients have easy access to information, and many want to conduct a Google search or do other online research before they commit to undergoing any treatment. The Internet is filled with a tremendous amount of valuable information; however, there is also information that has no scientific basis and may provide inaccurate opinions to our patients. Most of our patients lack the proper training to determine the difference between validated research and anecdotal opinion, so it is our job as healthcare providers to properly educate them. This education can help them make informed decisions about their healthcare. Historically, this was done by having a simple conversation with our patients; however, today, words alone may not resonate with our patients. The digital revolution has positively impacted many aspects of our lives. Unfortunately, one big negative is that the length of our attention spans has dropped dramatically. In the year 2000, it was estimated that humans had an average attention span of 12 seconds. In 2015, that number dropped to 8.25 seconds. This is now less than the attention span of a goldfish, which is estimated to have an average attention span of 9 seconds.1 In addition, research has has indicated that nearly 65% of the human population learns visually, while only 30% learns through auditory mechanisms, and 5% learn kinesthetically.2 Therefore, when we provide patients with verbal instructions only, nearly one third of them may be tuning out.
The success of any practice is dependent upon proper diagnosis and, ultimately, on the acceptance of the treatment plan by the patient. In order to achieve buy-in, our patients need to fully understand the treatment that is being recommended and why. In addition, practitioners need to demonstrate to patients that dentistry is not merely a commodity, and that the treatment that is being recommended is tailored to each patient’s specific oral health problems. In order to increase buy-in among our patients, various imaging technologies that leverage the power of visual communication can be used. In the past, when one thought of imaging in dentistry, the focus was generally on radiography. Today, radiography is only one of many imaging modalities that can be used to help with patient education. A host of new digital technologies, including caries detection units, intraoral and extraoral cameras, near-infrared transillumination, and intraoral scanning can be utilized to educate patients about their oral health. These technologies can be further leveraged by displaying the resulting images on a tablet computer. This article provides an overview of various imaging technologies in the marketplace and discusses how they can be used to enhance patient education.
The first radiograph was exposed in November 1895 by Wilhelm Konrad Roentgen, and since that time, image quality has continued to improve in conjunction with a decrease in radiation exposure.3 Radiography will continue to be used as a diagnostic medium in dentistry for the foreseeable future, and the images can be utilized to educate our patients about new issues as well as changes that are evident over time. The vast majority of radiographs taken for dentistry today still utilize 2-dimensional imaging. Historically, only a trained individual could recognize subtle changes on 2D images taken at different periods of time; however, today, digital imaging allows for the enlargement of these images and facilitates side-by-side comparative analysis (Figure 1 and Figure 2). Some manufacturers have developed software algorithms to evaluate digital images that can alert the clinician to areas that may show potential caries. Programs such as Carestream’s Logicon Caries Detection software can also be used to educate patients by overlying traditional digital radiographs with various annotations that show the existence of and potential progression of disease.4 Software analysis of various data sets will continue to evolve in the world of 2D radiography, and one need only look at the current state of 3-dimensional imaging to gain a sense of where diagnostic improvements can be made.
During the last 10 years, there has been tremendous advancement in 3D imaging with respect to dentistry. In particular, cone-beam computed tomography (CBCT) has been utilized to plan orthodontic cases and implant surgeries, navigate complex radicular anatomy, and aid in the evaluation of proper airway space—as well as a multitude of other functions that have made dentistry more predictable. One area in which it can be utilized further is that of patient education. Patients are much more likely to understand 3D anatomical form versus a small nuance on a 2D radiograph. A clear example of this is evident in implant planning. If a patient has a bony defect, and an implant needs to be placed in this site, virtual planning can easily illustrate to the patient that bony augmentation may be needed in order to achieve greater implant stability and success (Figure 3). Practitioners must adhere to the ALARA principle, which mandates that doses of ionizing radiation be kept “as low as (is) reasonably achievable.” But if a volume of data needs to be captured for diagnostic reasons an opportunity also exists for the practitioner to use the images to educate the patient and distinguish his or her practice as technologically innovative.
An increasing number of patients are concerned about cumulative radiation dose, and while ionizing radiation is generally relatively low in the dental office, new digital technologies that do not emit ionizing radiation have come about that may aid in diagnosis and provide patient education opportunities. These devices focus on caries, fractures, and periodontal issues, including the distinction between new and old plaque as well as healthy and inflamed gingival tissues.
Historically, dentists around the world were taught that when an explorer stuck into the tooth, the patient had caries, and a restoration was mostly likely needed. Unfortunately, the dental explorer has only been shown to have a 24% sensitivity rate, which means that histological caries are actually discovered only 24% of the time when using this instrument, leaving 76% undiagnosed.5 Equally important is the fact that many patients were unable to truly understand this modality. Today, diagnostic technologies are much more visual and can provide what amounts to “a digital second opinion” by offering a different perspective than traditional clinical and radiological examination. Caries detection devices such as CamX Spectra (Air Techniques) and SOPROLIFE (Acteon) offer fluorescence-based technology that can help differentiate diseased tooth structures from healthy ones. The coloration spectrum allows patients to see areas of concern easily.
With respect to the CamX Spectra, patients can be shown a visual and numerical presentation (Figure 4). The device works by using light at a 405 nm wavelength to stimulate porphyrins—a byproduct of Streptococcus mutans. The porphyrins are essentially being used as a tracer to diagnose caries at an early stage, and this technology has been shown to have a 97% sensitivity rating.6
The SOPROLIFE emits light at a 450 nm wavelength, which excites a light fluorescence signal re-transmitted by dentin. When the dentin is healthy, a green hue is apparent on the digital image, and when the dentin is infected, a dark red hue is apparent. Unlike the CamX Spectra, no numerical value is paired with this image; however, research has shown that the Soprolife also has a high sensitivity rating (87%) when compared to the sensitivity of a dental explorer.7 Although both of these cameras focus on the diagnosis of occlusal caries, the SOPROLIFE has also been shown to be helpful in the diagnosis of approximal caries.
Another promising imaging technology that has come to market over the last few years is the CariVu (Dexis). It uses a wavelength of light that facilitates near-infrared transillumination to detect caries on both the occlusal and proximal surfaces as well as cracks (Figure 5 and Figure 6). At this relatively long wavelength, enamel becomes transparent to photons, whereas porous lesions trap and absorb the photons. This phenomenon causes any lesions to appear dark. This technology is especially helpful at diagnosing approximal caries without the need for ionizing radiation. When teeth are illuminated and imaged from the occlusal surface, approximal caries will clearly show up as dark areas extending from the approximal surface towards the dentin. A clinician can then share this image with the patient to easily and clearly show the progression of disease instead of trying to explain radiolucency on a bitewing radiograph. While this technology does not entirely replace bitewing radiographs, it may minimize the need for radiographs among periodontally stable patients. Recent research suggests that near-infrared transillumination is an effective method for diagnosing lesions involving only the enamel as well as those involving the enamel and dentin.8 This technology has also been helpful in visualizing cracks on teeth. Cracks prevent light transmission and will appear as dark spots, alerting the clinician to potentially significant issues and allowing for more conservative treatment.
Periodontal disease is an issue that we face with our patients on a daily basis. Generally, the diagnosis of periodontal disease occurs via an analysis of periodontal probings, gingival attachment levels, radiographs, and qualitative assessment. These modalities can provide great insights to the trained practitioner, but many patients struggle to understand the importance of the negative impact of a 5 mm pocket or an area of inflammation when they do not feel any pain or visually recognize these problems in their own mouth. Similar to the SOPROLIFE, the SOPROCARE (Acteon) also helps detect caries via fluorescence technology; however, this device also has a periodontal assessment feature. This feature highlights gingival inflammation to differentiate it from healthy tissue and distinguishes new plaque from old plaque. A recent study found that it facilitates reliable evaluation of microbial plaque and gingival inflammation levels when compared to well-established models, such as the Silness and Löe gingival inflammation index.9 A device such as this can be used for patient motivation as well as education. In addition to displaying areas of concern via coloration of an acquired image, it can also help a patient see his or her progression back to health as areas of concern improve.
It can be argued that acquiring images via an intraoral camera and displaying them on a screen is one of the most powerful forms of patient education. Although there are many excellent intraoral cameras on the market today that provide highly detailed images, when a clinician hopes to educate a patient about smile enhancement, an extraoral camera should be used to provide the proper perspective and detail to the patient. A digital single-lens reflex (DSLR) camera outfitted with a macro lens and ring flash can help a practitioner capture beautiful images with minimal training. Unfortunately, many find these camera setups to be intimidating and costly, so implementation in the dental office has been limited. These concerns are addressed by the Smilelite MDP flash system (Smile Line USA), which can be attached to the vast majority of mobile phones today. This innovative yet simplistic flash system can provide near DSLR quality with the click of a smartphone. In addition, images taken on a system like this can be easily forwarded to the patient as well as a dental laboratory or specialist to further communication (Figure 7 through Figure 9).
Although 2D imaging is a great starting point to patient education, these modalities only provide part of the story to patients. Another technology that can allow for a robust patient education experience is an intraoral scanner. Unfortunately, many dentists see intraoral scanners as simply a replacement for impression material, but today’s scanners do much more than simply replace impression material and in many ways can serve as the information centerpiece of proper patient education. Intraoral scanners produced by 3Shape, Condor, Align, Carestream, Sirona, 3M, and others can quickly acquire a full-arch data set, and the data captured from these devices can easily be displayed on a screen to enhance patient communication. Unlike 2D images, one can rotate and zoom in on any area of the intraoral scan very quickly and show the patient any issues that may be present. Many practitioners are scanning their new and existing patients so that they can review the intraoral scans with the patient and discuss treatment options. Treatment presentations like this allow patients to have a truly immersive experience that increases buy-in into their oral healthcare.
One of the key benefits of digital technology today is that data sets (eg, radiographs, 2D images, 3D scans) can be captured very easily and displayed in a matter of seconds on essentially any screen. An additional benefit is that various types of digital technology can efficiently be merged together. For example, by transferring images and intraoral scans to a tablet computer, patients can have a visual experience by seeing the image, an auditory experience by listening to clinician, and a kinesthetic experience by touching and interacting with the images on the tablet. In the past, images could only be displayed on a screen in the operatory or consultation room, so this is considered a significant step in the right direction for patient education and communication. Tablet computing allows this experience to evolve as patients themselves can now interact with their own digital data simply by touching the screen as they would do with their smart phone (Figure 10). Imaging modules such as the CariVu (Dexis) have associated applications that essentially allow a patient’s entire imaging history to immediately be displayed on a tablet computer. In many cases, intraoral scans can be pulled from proprietary cloud management services and viewed on a tablet or smart phone as well. For patients without mobile technology, these 2D and 3D data sets can be placed into a basic Microsoft PowerPoint or Apple Keynote presentation.
In order to truly build value in oral healthcare, patients need to understand that their oral healthcare team is doing much more than simply providing “cleanings” and “filling teeth.” To achieve this goal, oral healthcare providers can leverage the imaging technologies presented here to help convey the importance of oral health and increase patient buy-in through the power of visual communication.
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About the Author
Parag R. Kachalia, DDS
Tenured Associate Professor of Restorative Dentistry
University of the Pacific
Arthur A Dugoni School of Dentistry
San Francisco, California
San Ramon, California