The Digital Puzzle
Finding the technological solution to optimize patient care
Allison M. DiMatteo, MPS
Digital technology continues to advance on many fronts, and with these advances come opportunities to elevate clinical care. The development of a digital workflow that incorporates technologies such as digital scanning and chairside milling can streamline diagnostics, case acceptance, treatment planning, and communication, but most importantly, it improves the quality of the dentistry that clinicians deliver, which results in more predictable, successful long-term outcomes for patients. Inside Dentistry examines the reasons to consider going digital and how to seamlessly implement the solution that best fits your practice.
Since the concept and the technologies to support it were first introduced more than 30 years ago, industry stakeholders suggest that more than 20,000 dental practices have embraced some form of a digital workflow. The cornerstone of that workflow could be digital impressions, CAD/CAM, and/or digital radiographs. However, although the number itself may sound impressive, in the grand scheme of adoption of innovations, that level of dissemination over three decades really wouldn't "wow" typical investors. Moreover, of the practices that do have digital dental technologies, it's further estimated that, excluding digital radiology, only a small percentage are regular, daily users.
"Digital dental technologies have been slow to penetrate the marketplace for many reasons, including cost and learning curve," observes Edward McLaren, DDS, MDC, a professor at the University of Alabama at Birmingham Dental School who also maintains a private practice limited to prosthodontics and esthetic dentistry. "Twenty years ago, any other technology investor would have looked at how long it was taking to achieve this level of diffusion and said that's not typically the timeline they're looking for. They'd typically want to see 20% to 25% market penetration at 10 years and more than 50% by now."
However, during the past 12 to 18 months, digital impression scanning has been one of the fastest growing areas of digital technology, according to John Cox, vice president of technology sales for Henry Schein Dental. He believes that this can be attributed to more dentists recognizing the return on investment that digital impression scanning yields in the form of enhanced patient communication experiences, more accurate impressions that result in fewer remakes and chairside adjustments, and savings offered by many laboratories for using digital impressions rather than analog ones.
"Clearly, the dental practice is a business, and any time you invest in something that you practice with, you have to look at its return in terms of your workflow and what it will do for your patients. If it empowers you to provide better care, then generally, that's a good return on investment," says Gary Kaye, DDS, of the New York Center for Digital Restorative Solutions in New York City, who notes that the return on investment from digital dental technologies is multi-effectual. "Digital technology may improve efficiency and deliver a return by saving you time in the process. It may also improve accuracy and deliver a return by eliminating or reducing errors and the need for remakes."
Benefits of Chairside Scanning and In-Office Milling
According to Cox, there are significant benefits that practices can experience from workflow automation and optimization because this conversion eliminates many of the manual processes that typically contribute to inefficiencies and errors.
"Going digital can benefit all types of practices, including solo practices, specialty practices, multiple location practices, and large group organizations," Cox explains. "We've seen all types of practices adopt digital workflows to enhance the patient experience (which drives more referrals), provide a more predictable quality of care (which drives better clinical outcomes), and improve efficiency and productivity (which increases practice profitability)."
"These days, digital scanners produce impressions that are as accurate or more accurate than those produced by conventional methods, while requiring less time and being much more patient friendly," notes Clint Stevens, DDS, a private practitioner in Tulsa, Oklahoma. "Chairside milling further enhances patient outcomes, not only through the convenience of one-visit dentistry, but also by eliminating many of the potential complications associated with a 2-week provisionalization period."
For example, the ability to fabricate restorations chairside allows for optimal adhesive bonding, because the optimum tooth surface to bond to is a freshly prepared one, rather than one subjected to contamination over time due to a provisional process, explains Dennis Fasbinder, DDS, clinical professor in the Department of Cariology at the University of Michigan School of Dentistry. When compared with any other type of adhesive restoration, chairside CAD/CAM restorations potentially have the lowest rate of postoperative sensitivity, he adds.
According to Mike Selberis, chief information officer for Glidewell Dental, a comparison of laboratory data on returns from digital impressions with data on returns from physical impressions reveals a significant advantage to going digital. An all-digital process eliminates many of the errors associated with making plaster models, especially in cases involving single-unit and small-span bridges, he says.
Purchasing a complete chairside solution-which includes CAD software, a milling unit, and an intraoral scanner-allows dentists to enhance their workflow by performing same-day dentistry. Selberis explains that in this scenario, after the impression scan is captured, the CAD software proposes a restoration design for the dentist to review and adjust as necessary prior to sending it to the milling unit, where the restoration can be milled and then seated in a single appointment. However, it should be noted that, in the technology's current state, more expensive laboratory mills still outperform in-office units in some ways. So, for certain cases that require more complex or nuanced restorative solutions, dentists should understand that they can still experience the benefits of going digital while using a laboratory for the milling process.
Because digital workflows are-by definition-CAD/CAM based, the use of all modern, monolithic materials is possible in the dentist's office, explains Selberis. Among them is fully sintered zirconia, which doesn't require an oven. With such a solution, a zirconia crown can be produced chairside from initial scan to final cementation and delivered in as little as 45 to 60 minutes.
From Fasbinder's perspective, the biggest advantage is the ability to deliver ceramic restorations such as crowns, onlays, veneers, and implant crowns in a single appointment, which represents significant time and cost savings to both dentists and patients. Chairside digital dentistry is also a process that patients undoubtedly desire, because very few people would report that they want to spend additional time at the dentist for treatment.
"It has been documented that when patients go to the dentist, even for a ‘short appointment,' they ultimately miss at least half a day of work or need half a day of child care," Fasbinder adds. "Delivering a final restoration in a single appointment offers much more savings to the patient than multiple 20- to 30-minute appointments."
"In terms of process efficiency, time savings, and cost savings, if you're able to provide a final restoration in one appointment, that makes the patient a lot happier," observes Gregg A. Helvey, DDS, MAGD, CDT, an adjunct associate professor at the Virginia Commonwealth University School of Dentistry in Richmond, Virginia. He adds that when you consider the overhead costs associated with a return patient visit (eg, chair time, staff time, time going through the same protocols, additional disposables), a single-visit restoration also makes dentists happy, particularly because their profit is the difference between what the patient pays and their overhead. "With everything done in one appointment-without reoccurring overhead costs-there's a big savings both time-wise and money-wise."
According to Selberis, another obvious advantage of a digital workflow for dentists is the time saved by being able to submit a digital impression to the laboratory immediately after scanning the patient. Further time saving is realized when the laboratory does not have to spend a day making and scanning a plaster model. In addition, digital scans can be more accurate than traditional polyvinyl siloxane impressions, resulting in not only faster turnaround times, but also better fitting crowns and bridges-and subsequently, fewer returns.
"Digital processes facilitate better communication with the laboratory as well as with dentists themselves," observes Helvey. "If you are working on a very large or complex case, it's possible to make a scan, assess the scan and preparation on a screen, and then send it to the laboratory to view it to determine if any alterations are needed."
Helvey elaborates that when preparing a tooth, dentists lose a lot of the reflective capability of the tooth structure, so they're unable to see aspects of the tooth and preparation that they can visualize on a scanned image. Therefore, examining a digitized preparation in three dimensions can actually make a dentist more technically precise, particularly because digital scanners are very sensitive when capturing tooth anatomy (eg, margins) that must be clearly defined.
Helvey adds that the difference between a traditional impression, which is a negative image of a tooth that doesn't represent the preparation design until it's poured into a model, and a digital impression scan is that the latter is much clearer and enables easier visualization of anatomical details. Oftentimes, what the impression looks like after it's poured is different than what the dentist anticipated, or there may be bubbles or voids in the margin areas that require the impression to be retaken. When you digitally scan preparations, you can see everything exactly. As a result, if dentists can't clearly see the margin or if it's covered with blood, they can go back, establish hemostasis, and then easily make a final scan.
Furthermore, because many laboratories follow a modeless process that doesn't require printing a model to fabricate the restoration, some will pass these savings on to the dentist, Selberis adds.
Numerous milling materials and restorative choices afford an abundance of opportunities to provide patients with the best treatment option, says Daniel Alter, MSc, MDT, CDT, professor of restorative dentistry at the New York City College of Technology and executive editor of Inside Dental Technology. Whether the dentist chooses to use one of the new multilayered or translucent zirconias (eg, full-contour or layered) or selects a material from the wealth of ceramic and resin/ceramic hybrid choices available, all provide an elevated level of functionality and esthetics.
"Many CAD/CAM materials can be both hand polished and surface glazed, depending on the level of esthetic value required by the case," explains Fasbinder, noting that the esthetic outcome is more of a function of the fabrication process than the CAD/CAM technology. "CAD/CAM processing creates the volume of the restorations, whereas surface texturing, contouring, and shade modification influence the esthetic outcome. More anteriorly placed restorations require a greater degree of surface shade customization, which can also be completed using an in-office protocol."
According to Alter, each material possesses different characteristics that translate to different benefits for the patient. Therefore, it's prudent for clinicians to become acquainted with these materials or partner with a knowledgeable laboratory to make appropriate selections. When selecting the most appropriate material, some factors to consider include cementation versus bonding, the antagonist situation, margins, shade, and the underlying tooth structure, he says.
When it comes to making the move to digital dentistry, the question is not "if" dentists will adopt digital technologies and workflows, but "when." The timing depends on many variables, explains Cox. These include the results that the dentist expects digital technologies to deliver, the ability of the practice's network infrastructure to support the addition of new technology, and whether the network is robust enough to optimize the digital workflow. These variables determine which digital technology solutions will best meet the practice's needs and be scalable to support future growth and expansion.
For example, in the future, don't be surprised to see fully integrated 3-dimensional printers added to the chairside digital workflow. With 3D printers, restoration designs are sent to a printer for fabrication, much in the same way that they're sent to a mill. Today's 3D printers are already being utilized to produce implant surgical guides, night guards, and models for creating orthodontic aligners.
Therefore, Selberis advises, when purchasing a new chairside solution, it's important to look for one that is platform-based, allows a 3D printer to function within the existing digital workflow, and simultaneously integrates seamlessly with the laboratory. These more advanced solutions will enable dentists to work more closely with the laboratory and choose the workflow and material that is best suited for the patient in any particular situation.
"One distinct advantage would be the ability to send scans to the laboratory to produce digital designs, which could then be sent back to the dentist's office for milling or 3D printing while the patient is still there," Selberis explains. "This new workflow is better suited to multi-unit cases, for which it might not be in the dentist's best interest to design a larger or more complex restoration when he or she could be seeing more patients instead."
To go digital, practices need access to capital, Cox says. They also need to decide if they are focused on adding new technology or adding new locations and determine if they are prepared to implement additional protocols or clinical changes in the practice.
This means that the success of technology adoption and integration is inherently tied to buy-in by the dental team, who should be empowered to be part of the process and actively engaged in using the technology, Stevens emphasizes.
"Once they see how positively it will affect their daily tasks and patient outcomes, it should be easy to get them on board," Stevens says. "Even the most resistant team members should eventually come around."
According to Cary Goldstein, DMD, an Atlanta-based prosthodontist at the Goldstein Dental Center, dentists cannot implement a digital workflow on their own, which makes team member buy-in and training essential. He shares that in his practice, if he had to be the one to take all of the impression scans, then design the restoration, and finally finish, polish, and fire the milled restoration prior to cementation, he wouldn't be effective.
"That would take too much of my time and negate the benefits of a digital workflow," says Goldstein, emphasizing that for him, the biggest advantage of a digital workflow is the time savings. "With a well-trained team, I gain time because I don't have to send crowns out to be made or make temporary restorations. Because everything is completed in one visit-and it's my team that's designing, milling, and firing the crown while I'm in a different operatory performing another crown preparation, filling, or hygiene check-I don't have to schedule seating appointments and now have more time in my schedule."
Overcoming Barriers to Technology Integration
It's important to remember that adopting and integrating digital technology into a practice often requires changes to both clinical and business workflows. Although they can ultimately be beneficial, such changes are disruptive. This underscores the need for dentists to choose a technology partner-not just an equipment vendor-that can help their teams navigate and support a successful implementation.
Therefore, Kaye says, when selecting technology, it's imperative that dentists examine the supplier that will be bringing the technology to them. The technology and its successful integration and use will require training and support, and both should be in the hands of those who are closest to the equipment and know it best.
"Do your research and pick the supplier that will give you the necessary training and ongoing support that you need, because they're the one with access to information and feedback about the technology, including what's working and what isn't working," recommends Kaye. "Partnering with an engaged supplier that really backs their equipment makes a huge difference and is a very crucial component of being successful."
Stevens acknowledges that there are many manufacturers and distributors involved in selling digital scanners and mills, each with a different approach to integration and customer education and training. He says that perhaps the most important aspect of choosing a system is ensuring that the dentist and practice-essentially the customer-receive the best support possible in terms of integration, training, and continued customer support.
Otherwise, dentists may fail to optimize digital solutions to their fullest, says Cox. He adds that Henry Schein Dental develops and delivers a comprehensive training program to ensure that dental practice teams are both competent and confident in utilizing new technology. The program includes a 90-day, post-installation "technology coach" who partners with team members to advance their success.
"Any office that is truly committed to adopting technology will be better and more productive in less time than they ever were with conventional workflows," Stevens says, adding that digital scanners have become faster and more accurate and that CAD software and mills have never been better or more user-friendly. "However, as with any new product or procedure added to the practice, digital scanning and chairside milling present a learning curve when integrating them into existing workflows."
According to McLaren, that learning curve will involve a new understanding of tooth form and esthetics. Although CAD software tooth libraries and CAM machines do a reasonable job of designing and producing restorations of tooth-like shape and form, dentists will still need to learn some basic restoration design skills-such as manipulating 3D models on a computer screen as well as performing custom external finishing, staining, and glazing, he adds.
"It's like anything else in dentistry that we do that requires a certain amount of learning, doing, refining, and improving," explains Kaye. "Chairside scanning is just like taking an analog impression. Nobody who takes analog impressions got it right the first time; it required learning the techniques, materials, what to look for, and how to evaluate success."
You've Got Options
If you're not ready to adopt a fully integrated digital workflow, take heart. You're not alone, you do have options, and you can still benefit from the digital process. Dentists can continue using conventional impressioning methods and sending the impressions to the laboratory, where they can either be scanned directly or used to pour a gypsum model that is scanned.
"Once the impression or model is digitized, dentists can expect a greater level of precision and marginal integrity and experience the benefits of the latest restorative materials available for CAD/CAM innovations," Alter adds.
However, it's important to choose a laboratory partner that specializes in digital workflows, cautions Selberis, because a well-trained technical support team can provide immediate assistance when dentists need it most, and this is critical to long-term success. Having laboratories provide simple and powerful workflows that enable dentists to make the best decisions when choosing how and where to make the restoration is the ultimate digital workflow solution, he explains.
"This is where I believe that the Digital Dental Team-a term I've coined in my lectures-comes into play," McLaren points out. "The concept of the Digital Dental Team involves the dentist and/or dental practice scanning the patient with a digital scanner and sending the digital impression to the laboratory, where the restoration is either designed and sent back to the practice for milling or designed, milled, finished, and returned to the practice the same day, if operated locally."
Selberis believes that this is the promise of the new era, where it's as if the laboratory is accessible inside the dental practice office, allowing dentists to make the material and manufacturing choices that best suit the needs of each case-every time.
Alter suggests partnering with a well-versed and knowledgeable dental laboratory to help make transitioning into digital dentistry easier and minimize the barriers to achieving great results. Laboratory partnerships can also produce innovative and collaborative efforts for patient acquisition and marketing the practice as state-of-the-art and high-tech.
Compared to what was available 20 years ago, today's technologies enable much more intuitive, automated, and efficient processes that result in predictable outcomes that have been documented to exhibit long-term clinical success, Fasbinder emphasizes.
"Especially in the last 5 to 6 years, I think the leaps and bounds in digital technology have brought it to the point where we should now be asking, ‘why wouldn't you have digital technology in your practice?'" Helvey adds.
However, advises Cox, for individual dentists and their practices, the success of any newly implemented technology can be measured by asking three questions: Does the technology deliver an enhanced patient experience? Does the technology contribute to more predictable quality treatment outcomes? And, does the technology improve practice efficiency and productivity? If the answer to these questions is yes, then the practice has made a good purchase decision.
"Dentists need to realize that digital scanners and milled restorations are no longer niche products, but rather the norm in today's dentistry-and there has never been a better time to go digital," Stevens emphasizes. "The best thing they can do is become educated on what today's systems can offer their practice, find the solutions that are the right fit for them, and get plugged into the present and future of dentistry."
According to Kaye, any time dentists can incorporate technology that makes processes more efficient, team members more engaged in providing better dentistry, and dentists better dentists, it's a win-win for the practice and for patients. "It's a no-brainer," Kaye concludes, "and there's no reason not to embrace this technology today."