This month: High-Tech Possibilities

Sept. 1, 2001
Today we will be visiting with Dr. Paul Feuerstein about technology as we see it in the present day and in our profession:

with Dr. Paul Feuerstein

Today we will be visiting with Dr. Paul Feuerstein about technology as we see it in the present day and in our profession:

  • where it's moving
  • access to information
  • the potential of being able to have information held in cyberspace for access via pass codes whenever desired
  • what we can do with some new camera-image capture capabilities

Dr. Jameson: Dr. Feuerstein, what do you see as the portions of technology in use today that are changing the most rapidly?

Dr. Feuerstein: I think that the one specific area that has evolved most rapidly in dentistry, in business, and in the world in general has to be the Internet itself — the Web. It has single-handedly changed the way everybody does business every single day of the week. You can't do anything today without someone saying, "Check out our Web site," or "Send me an email," or even "Send me an email on my cell phone."

The Internet has become the primary way information is transferred. Information itself has been required to be written, and now in digital form it is readily available. In dentistry, we give information, we gather information, and we share information in different formats. We must be ready to move in the dental profession along the same route that the rest of the world is going.

Dr. Jameson: Traditionally, we use management software to control a lot of the information in our practices, to be able to use it for patient education, etc. Where do you think things are headed in the development of ASPs, and how will this affect dental practices in the future?

Dr. Feuerstein: First of all, Internet speeds in the home and the office are increasing rapidly. Cable modems and DSL lines are available at their lowest costs ever. At present, cable modems are not readily available in the business world, because cable companies don't have the capability of servicing all those people. However, I think that will be remedied in the future. I think the DSL system will be adopted a little bit quicker, and it should become more reliable and faster. Once that's in place, then we can start getting involved with ASPs, the application service providers.

ASPs will change the way we operate our computers. Instead of having software reside on your own computer, the software itself will be somewhere else. For instance, while I'm in Massachusetts, my data could be in Chicago. I can dial up the software and it will have all of my patient data and practice information. I can access it from my office, my home, or from anywhere — which could be a boon to offices with multiple locations. Your data will all be sitting in there, and you'll have no problems backing it up, because you don't have anything in your office computer to worry about; it's all automatic. If the ASP company wants to do a service or software update, that can happen on their end; you don't even have to think about it or do anything. You just pay a monthly fee for the whole thing.

A couple of nondental companies are now actively performing this service. There's a company called NetLedger, Inc., started by Larry Ellison, founder of Oracle, running an ASP that they feel may take over what Quicken does right now (like an online Quicken).

The concept of the ASP will grow, but I don't think it's going to happen overnight. There's a learning curve — security issues, firewalls, legality issues, and confidentiality issues of data floating around on the Internet. There's absolutely no problem — data is secure — but dentists have to be sure that it's absolutely a proven thing. All of the major practice-management companies that we're aware of are looking at ASP models. Dentalxchange is currently online with Practice Connect. The others are working hard on it, but they're not committing to it as of yet to make sure all of their pieces are ready.

Dr. Jameson: I would definitely agree that ASPs are a bit premature, but this is fabulous information for readers to have. That was probably the most enlightening view of ASPs that I've ever heard, because it didn't go into such depth that makes it difficult for most of us to understand.

I know you're dealing quite a bit with image capture and image control. Let's talk about the actual storage of digital images via digital cameras, intraoral cameras, etc. What do you think is one of the hottest things today for doctors to look at that can become a profit center in their practices? Is there anything that practitioners can use in their offices that will increase their bottom line and increase case acceptance?

Dr. Feuerstein: My feeling is that things have changed over the past couple of years. We were very happy for years to do initial examinations and chart all of the patient's existing restorations. Then intraoral cameras were introduced, and dentists began to take pictures all over the place. You take a full series of X-rays, bring them up to the patient, hold them up to the light, and say, "Look at the little black spots." The intraoral pictures were a good next step.

Now, we still take a full series of radiographs — traditional or digital; it makes no difference — but we also take a series of photographs. If it's a routine case, most of the time we will have the patient smile, take a picture of the smile, take a picture of the full face, and then take one upper arch with a mirror and one lower arch with a mirror. This can be done with a digital or Polaroid camera for instant results, or even with a 35 mm for a later consult. You don't have to do any charting; the photos are the charting. It's a lot better than round circles with blue and red dots in the middle!

Now, whether it is a digital image, a digital print, an image in a computer, or a Polaroid photo, it can be made part of the patient chart. With the patient sitting in my chair, I can point to things. The patient can still look in the mirror, but I can point to the photograph or the computer screen and show exactly what I'm talking about. As digitally oriented as my office is now, I happen to use the Polaroid Macro 5 often, because it's so simple to have a picture to hold in my hand for case presentation while the patient and I talk. If there's a real problem, we can grab the intraoral camera and zoom in on a particular tooth, fracture, or abnormality.

If you're very sophisticated, you can take the digital photograph on the screen and zoom in on a particular tooth. The quality of digital pictures is so good now with high-resolution cameras that you can actually zoom in on a full-arch digital photo and pick out an individual tooth. It could replace the intraoral camera in some cases.

As far as the digital camera itself, just as with computers, the hardware changes rapidly. My first camera, the Olympus 620, has 1.4 megapixels and the price was $900. Now it runs about $50 on Ebay, and it is probably a little over a year old. A current-model Olympus camera — for example, model 3030 — has three times the resolution. Side by side, the new digital camera is obviously the higher-resolution camera.

From a patient's standpoint, though, sharpness isn't an issue. The patient doesn't understand dentistry, so if I'm doing this for the patient, I'm not really hung up on having the highest resolution. If I were showing the picture to my peers or sending it to some other professionals, that might be a different story. In that case, I might want the higher-resolution, more expensive camera. From a patient-education standpoint, the idea is to show patients what problems they have and give them some information and a better understanding of existing conditions.

Dr. Jameson: How do you explain to patients what types of treatment opportunities are available in your practice?

Dr. Feuerstein: Well, that's the next step. Once you show the patient a picture of what the problem is, and if he still hasn't responded, then you have a couple of options. The old-fashioned option is to take some old composite shade A2, for example, and plaster it roughly over the anterior teeth. It takes about two minutes, and then you can photograph it. While the patient is looking in a mirror, peel the composite right off in front of his eyes. All of a sudden, the patient can see what he could possibly look like with veneers, and he has a picture to take home with him.

The other way to do this, of course, is to use software. There is some nice software available that enables you to do this same thing digitally on a computer. Image FX, DICOM, Digital Dentist, and Vipersoft come quickly to mind. You're not going to be able to do all this in two seconds on a computer, but with practice it is quick.

If you don't have time during the exam, you can have the patient come back at another visit and show a before-and-after image. There are several different ways to do this: You can do it yourself at chairside, or you can take a physical Polaroid picture or digital picture and send it out to a service that will do the imaging for you. The cost is typically between $35 and $80.

If you choose to do the imaging yourself, you also have four very high-profile people — Bill Dickerson, David Hornbrook, Lorin Berland, and Anthony Vocaturo — who put together a digital library of smiles that you can import into your patients' images. But the crucial thing is, you must be able to deliver it. You can't just say to a patient, "Here's what I can do for you" if you can't. You can do all the imaging you want, but if the patient has a physical picture in hand and your case doesn't end up looking like the photo, you have a real problem. Instead you have to say, "This is what we can potentially do for you." Most times, patients will ask how quickly they can get started.

Dr. Jameson: As we look at the changes that will happen with image capture, in what areas of our practices do you think we're going to see the most change in the future?

Dr. Feuerstein: I think that there will be a blending somewhere along the line between taking that digital picture and getting it into print. If you have a digital camera, you have to fool around with getting it from the camera to the computer on the screen so you can show it to the patient. The exception right now is the Sony camera that uses either a floppy disk, or a CD, that you just take out of the camera, pop into your computer, and it's there. This is quicker than the new technology that's out now. Otherwise, you have to use wires, little switches, and memory chips; plug them into a box; and then use software to get them on the screen. The current new idea is to use wireless downloads. Once the technology is perfected and thus faster, you'll be able to take a digital picture, push a button, and the image will be beamed over to your computer, appearing on the screen.

Dr. Jameson: There's a brand-new digital camera out on which you can use your existing 35 mm camera lenses, but it's a digital camera.

Dr. Feuerstein: One thing that is lacking, except for the very high-priced cameras, are SLR-like bodies with interchangeable lenses. Most current units are of the "point-and-shoot" type. It would also be nice if there were a blend of the digital and instant Polaroid. Imagine taking your series of digital photos, sorting through them, and then pushing a button to get instant prints of the best ones. Another new feature is in one of the current high-end cameras. It has a hard drive built inside — a 1 gigabyte microdrive — that can store far more photos as well as digital video clips.

In this time of digital cameras, though, there is an odd entry into the marketplace that I mentioned before: Polaroid's Macro 5. This camera, although it uses traditional instant film, is a wonderful tool for the dental market. It is very simple to use; has built-in, interchangeable lenses; and produces extremely clear and color-correct prints. It is excellent for communicating shades to a dental lab by varying light exposures as well as other uses. And if you want it to be digital, you just place it in a scanner that you buy at Circuit City or someplace for $100, and you have a digital image. This may all become moot in the future when everything is digital and we can easily exchange images over the Internet and via email. This technology is certainly here, but not mainstream ... yet.

Dr. Jameson: The digital image allows long-term storage?

Dr. Feuerstein: Yes, and it's easy to find instead of sorting through a shoebox full of slides and prints. I want to add another angle. We talked a little bit earlier about ASPs. There's a whole world of dentist-to-dentist, dentist-to-patient, and dentist-to-laboratory relations that can be improved by this technology.

Think about this: You have a digital picture and a digital or scanned X-ray. A patient is in the chair. He has a lesion on his tongue. I take a digital picture, and I can send it up to a Web site accessible only to certain people. I can get feedback from colleagues in my neighborhood or in Australia within minutes about what they think the lesion is and what's going on. In essence, I get a quick consultation sometimes before the patient leaves the office.

For referrals, it's the same sort of thing. You can take your images — digital images, X-rays, whatever — and email them to a specialist or put them up on your Web site and have the specialist, for security purposes, use a special password to get into the system and take a look at the case. Or, even better, if you have a complicated case, just put the case up on your Web site and give the password to 20 professionals ... and you'll get 20 answers overnight.

There is a company in my area out of Boston called Transcend Online that provides this service. They are working very hard at developing this technology right now. They have also developed a laboratory Web-based product. You can take digital images, pictures, or whatever and email them or go to a specific site and send them to a dental lab. This way, your images can have a very sophisticated prescription. Imagine no more lost lab slips or forgotten shades!

Another new wave of technology relating to shade-taking is here now — like the way Home Depot can match your paint color. There are machines that will actually match tooth color with digital accuracy. Two of the products are Shofu's Shade Eye and Cynovad's Shade Scan, which give consistent color-matching results, although they use different approaches. There are a few others that have just come into the marketplace this year.

Dr. Jameson: What about CAD/CAM technologies?

Dr. Feuerstein: Here you have a computer that's actually building restorations for you — the CEREC in-house and the Procera out of the office, with the lab using CAD technology. With CEREC 3, the patient has the entire procedure finished in one visit — no impressions or temporaries for single units. This product has come a long way since its introduction. Procera has recently introduced a three-unit bridge! There's a lot going on in the crystal ball in that realm.

Dr. Jameson: And this is what we're going to be dealing with in Dental Economics for our readers for the future.

Dr. Feuerstein: Without a doubt. And I'll do my best to keep up with it and continue to report to us all.

Dr. John Jameson is chairman of the board of Jameson Management, Inc., an international consulting firm. Dr. Jameson lectures internationally on high-tech dentistry and its integration into the dental practice. He provides research for manufacturers and marketing companies. Dr. Jameson may be reached at (580) 369-5555 or by e-mail at [email protected]

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