Aug. 1, 2006
Technology in the dental office is something near and dear to me. A few years ago, I wrote a column about digital diagnosis for Dental Economics®.

Technology in the dental office is something near and dear to me. A few years ago, I wrote a column about digital diagnosis for Dental Economics®. Surveys indicate that most dentists are interested in new technologies. Despite this, there remain barriers that seem to stop the final purchase of these technologies. I’ve heard it all many times ... “The technology is good, but I think I will wait for the next generation of products.” “I am waiting for the prices to drop.” “I am not sure that I can train my staff properly.” The future is here now. This month I talk with Dr. James Dunn about technology in the dental practice.

Dr. Dalin: Jim, in your lectures through the years, I have learned much about restorative dentistry. Today, though, let’s talk about technology in the dental practice. I know you are a proponent of this aspect of dentistry. I would like to list a few of these technologies and get your feedback on each. First, let’s talk about digital photography. Should every practice own a digital camera? How can a digital camera be used on a daily basis?

Dr. Dunn: Visual communication dominates our lives whether it be television, the Internet, magazines, video, computers, digital cameras, or cell phones. Dentists no longer can use only words, diagrams, or forms to communicate with patients and laboratories, or to document patient treatment. We all want visual communication, but we also want it now! Visual communication requires technology.

Let me make an early disclaimer about technology in the dental office. The more technology we incorporate, the more time is involved in using and maintaining the equipment, and collecting and managing the information. In other words, technology does not necessarily save time. But it does make the information visible, more useful, and allows the patient and dentist to make more meaningful decisions in treatment - usually almost immediately.

Visual technology creates a better understanding between the patient and dentist with diagnosis, treatment choices, and the quality of final results. Visual images are powerful marketing tools for dental practices. They increase accuracy in communication with labs and other dental practitioners. Dentistry exists in this world of visual technology. To be most effective, we must adapt the technology in our practices.

Digital photography is one of the most effective technologies dentists can implement. However, before incorporating digital photography, the dentist must decide how to use photographs in the practice. The dentist may want to choose one or more of three levels of dental digital imaging: basic, intermediate, or advanced. Each level may require different equipment, image quality, and use. In addition to these three levels, there are two types of dental digital photographs. One style of photos is taken for the dentist to use - retracted, occlusal, or medical portraits. The other style is for the patient - pretty smiles, glamour, or near glamour views. These photos represent how a patient may see him or herself and create an attractive photo the patient will show to others.

Let’s take a look at the three levels of dental digital imaging. The basic level includes “snapshots” for in-office, patient, and lab use. Snapshot-quality photos are effective communication tools for providing patients before-and-after treatment photos, chart identification, shade verification with laboratories, and treatment records. Photos are taken quickly, using modified point-and-shoot cameras, and are made in the office using small dye-sublimation printers. The entire process may take just a few minutes. Patients can receive the prints before leaving the office, a print can be sent with the laboratory prescription, or photographs can be enclosed with referrals or placed into charts. Usually, no photo management software is used, and the photographs may not be of sufficient quality for general marketing use. Most basic photographs are taken by dental auxiliaries.

The intermediate level includes marketing, Web use, portraits, and diagnosis. As compared to basic level photos, intermediate photo quality images have better artistic quality with attractive lighting and good composition. Thus, they can be used in general marketing or on a Web site. These photos are used in diagnosis and treatment planning and can be viewed on a monitor with a patient. The images can be managed with general photo and presentation software. Mirrors, contractors, and retractors are used in intraoral photos, and external smile or simple portraits are taken routinely. More sophisticated, modified point-and-shoot and entry-level single-lens reflex cameras are used. The dentist or auxiliaries may take the photos.

The advanced level includes artistic, professional quality photos for marketing and presentations. This level is for the dentist who seeks the highest quality in photo images and wants images that can be considered not only dental-representative but also photographically artistic with attractive lighting and composition. Images are usually well-organized and can be corrected via available software. The dentist may have “smile galleries” or treatment books, have an active Web site, use these photos in patient publications, make presentations to public or dental audiences, put the photos in dental publications, or for accreditation or membership in dental organizations. “Glamour” or simplified portraits of patients with post-treatment results can be used for marketing or be given to patients. SLR cameras with high-quality lens and lighting are used. Dentists usually take the majority of these photos.

Dr. Dalin: There are many types of cameras from which to choose. Kodak has a simple-to-use 7590 dental package. I also know that many dentists who enjoy digital photography purchase more professional systems. What are the advantages and disadvantages of these types of cameras?

Dr. Dunn: Consumer digital cameras with small capture chips and inexpensive lenses inherently give lower quality images. They have to be modified to take dental photos. Point-and-shoot cameras require add-on, close-up lenses and modification of the built-in flash for proper focus and light exposure. Professional-type single-lens reflex cameras have larger capture chips, and high-quality lens and flash systems that are designed for close-up photography.

The simpler the camera, the more the images will look like snapshots. Some modified point-and-shoot cameras have high-quality add-on lenses and effective flash diffusers. These provide acceptable quality images for most dental uses. The easier the camera is to use, the less control the dentist has to change exposure and lighting. Point-and-shoot cameras can be used with one hand for quick-photo capture. Many modified point-and-shoot dental cameras may not be much less expensive than entry-level SLR systems. The dentist who wants snapshot type photos would want to use this camera.

The more complex SLR cameras allow the dentist to modify lighting (amount and location) and exposure (lighter or darker) to make the image more attractive. Camera and flash settings can be set for repeated use, or they can be adjusted for changes in exposure and lighting. The dentist who wants to use photos for marketing and public presentations would want to use a dental SLR camera system. These systems are heavy and require two people to take the picture. One person holds the camera while another handles the retractors, contractors, or mirrors.

For dentists who want a simplified camera for quick photos but also a camera to produce higher quality images, I recommend they use both types of cameras.

Dr. Dalin: In terms of printing, do you have a preference for inkjet, photoprinter, dye sublimation, or laser printers?

Dr. Dunn: For sharing photos when prints are best, a 4 x 6-inch dye sublimation printer is an essential part of the dental office. This camera can be connected to the printer for direct printing, the memory card can be inserted into the printer, or the image can be controlled by a computer. Printing occurs in less than a minute and for less than $1 a print. This printer can be used with or without a computer. Dye-sublimation prints are high-quality photos.

For all other printing uses, inkjets are available in low to high quality. Prints can range from small to wall-size prints for smile galleries. These printers require a computer and include software to adjust the print to the quality desired. Dentists who take portraits use high-quality inkjet photo printers to display the quality of the image. Treatment plans or photo collages can be printed quickly for patients. These printers are expensive. But the largest expense is in ink and the time involved to print.

Laser printers are good quality, but have been replaced by inkjet printers except when multiple copies are needed.

Dr. Dalin: For years, I have been a huge fan of digital radiography. Every dentist takes radiographs, yet the majority of offices have not switched to this technology. There are several advantages with this technology - less radiation for patients, no film or chemicals needed, great quality of images, fast capture of images, great patient communication. What else can you add about the benefits of digital radiography?

Dr. Dunn: Although we understand the advantages of digital X-rays, the cost and complexity of outfitting an office electronically for this technology can be threatening. Sensor size, cost, and susceptibility to damage also have discouraged many dentists from adapting digital X-rays. The technology is exciting. Medicine has adapted digital X-rays, but primarily the phosphor plate technique. As more dental offices become computerized in each operatory, digital X-rays will be the standard of care.

Dr. Dalin: How about intraoral cameras? Do you think offices should obtain this technology?

Dr. Dunn: With easy-to-use dental digital cameras, the intraoral camera will be used less. The intraoral camera is quick and easy to use in molar areas, but the image quality is low and not easily stored on computers. I think digital cameras will replace traditional intraoral cameras.

Dr. Dalin: What are your thoughts about the DIAGNOdent instrument? I understand this technology is in a “pen” format.

Dr. Dunn: Dentistry lags behind medicine in using diagnostic technology. The introduction of this technology, such as the DIAGNOdent, is an enhancement to our diagnostic armamentarium. This technology is not yet conclusive. But improved technology is being developed, and eventually will be considered part of the essential diagnostic options much like we currently view X-rays.

Dr. Dalin: How should hard- and soft-tissue lasers fit into the dental office?

Dr. Dunn: There is no controversy that lasers are efficient when used on soft tissue. The use of lasers in hard tissue modification is less clear. There is no doubt that lasers can cut or modify tissue. Currently, most discussions deal with the practice-management concerns of laser use in a dental office. Do they give an appropriate return on investment or do they provide a perception of technology in the office to patients or prospective patients?

Dr. Dalin: What do you think about CAD/CAM units, such as the CEREC?

Dr. Dunn: As CAD/CAM technology improves and the supply of trained laboratory technicians decreases, the dentist will need a source of high-quality indirect restorations. The advantage of one-appointment, indirect restorations is economically attractive, as is the decrease in trauma to the patient. One concern is the often extended learning curve in designing the restoration with the graphic software. Some dentists do not, or will not, learn the software so that design will be quick. Since younger dentists are more experienced and proficient with computers, we predict that these dentists will adapt easily to the software-designed, CAD/CAM restorations. Also, we think the technology will be integrated as an option for indirect ceramic restorations.

Dr. Dalin: How about computerized shade-taking devices? Are they accurate?

Dr. Dunn: Again, technology continues to improve and the ability to correctly measure the human tooth with its complex shading and translucency will be another routine technology available to dentistry. The human tooth is an art object. Often, only an artistic ceramist can duplicate the subtleties of nature. Chronometers and spectrophotometers are used extensively in the industry to measure color. I have no doubt they will also be routine in dentistry. One concern is that each dentist and laboratory must use the same system to be effective.

Dr. Dalin: What about patient-education systems, such as CAESY? Many of the new systems allow you to create presentations. Do you prefer this option?

Dr. Dunn: We must remember that education presentations are for the patient. When patients are used to the quality of television and theater presentations, not many dentists can compete. Pick a recording that is both educational and interesting. Dentistry competes with the professionals. Patients learn best with that type of quality.

Dr. Dalin: One of the main objections to implementing these new technologies is the idea of dentists working them into their routines. I advise dentists to introduce each technology separately and in a systematic manner. In other words, get a technology, train everyone, work it into the routine, and master it. Then you can move to the next item. I think it is too difficult to try to implement multiple systems at one time. Do you agree?

Dr. Dunn: Absolutely. The worst technology is one that is not being used to make your practice better.

Dr. Dalin: Is there anything else about technology in the dental office that you wish to discuss?

Dr. Dunn: Buy technology for what you want to accomplish, then learn to use it routinely. If it does not enhance your practice, then reevaluate it for relevancy or your application of the technology. I do not believe that every practice has to incorporate technology to give quality dental care. Therefore, some practices may be better off without many of the technology items we have discussed. Dentists who choose not to incorporate available technologies will be missing productive and helpful tools for their practices.

Dr. James R. Dunn is a School of Dentistry faculty member at Loma Linda University in Loma Linda, Calif. He is responsible for the instruction of appearance-related dental treatments and dental photography. Dr. Dunn is active in biomaterial research in bonding materials, directs a study club in esthetic dental treatments, and lectures and conducts workshops nationally and internationally on clinical esthetic bonding treatments. He is an active member in the American Academy of Esthetic Dentistry, the American Academy of Cosmetic Dentistry, the International and American Association of Dental Research, Academy of Dental Materials, and other dental organizations.

Jeffrey B. Dalin, DDS, FAGD, FICD, practices general dentistry in St. Louis. He also is the editor of St. Louis Dentistry magazine, and spokesman and critical-issue-response-team chairman for the Greater St. Louis Dental Society. Contact him by e-mail at [email protected], by phone at (314) 567-5612, or by fax at (314) 567-9047.

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