Adopting new charting, imaging, scanning, and in-office design and milling technologies can streamline office workflow and help improve care
Innovations in dentistry are changing the way oral health professionals manage patients. Advances in digital technology, in particular, are providing new diagnostic tools, documentation capabilities and fabrication methods that enhance clinicians’ ability to provide optimal care. The intent of this paper is to help illustrate the expanding scope — and advantages — of digital technology in contemporary dental practice.
Successfully promoting oral health begins with identifying patients’ oral health risks and behaviors.1 This enables dental teams to obtain relevant diagnostic information. Keeping complete and accurate records is not only important clinically, it is required by law. Fortunately, digital technology has made record keeping simple. Clinical records can be collected and managed in digital formats using special software. Besides the space-savings advantage, this allows clinicians to easily access medical and dental histories, even remotely, for evaluation prior to a patient’s in-office examination.
One of the current limitations of electronic dental records is they are largely incompatible with existing electronic health records. With the growing emphasis on the association between oral health and systemic health, the ability to communicate easily and accurately with physicians, nurses, pharmacists and other health professionals is increasingly important. Consequently, the integration of electronic dental records with digital medical records should be promoted interprofessionally.2
Digital technology facilitates accurate assessment of community needs by providing the basic documentation necessary to better understand the incidence and prevalence of diseases, as well as factors that represent risks to individuals within the community. Management and utilization of large data sets are emerging as powerful tools to aid health care providers and policymakers. Fully integrated electronic dental and medical records will enable faster and better communication between clinicians, payers, laboratories and researchers.3
Intraoral digital cameras are useful for documentation and patient communication. Because images of the oral cavity can be shown in real time,4 this technology can be a remarkable motivator for patients. Such images facilitate discussions regarding patients’ needs at the time of treatment planning and help promote case acceptance. Digital photographs can also be incorporated into esthetic treatment planning, during which patients can envision the beneficial effects of therapy before treatment begins.5
In addition, as part of the digital dental record, intraoral and perioral photographs can be useful in longitudinal assessments of oral health and help improve communication between dental team members. Finally, intraoral photography contributes to the integrity of dental records from a medico-legal perspective.
- Advances in digital technology are providing new diagnostic tools, documentation capabilities and fabrication methods that enhance clinicians’ ability to provide optimal care.
- Digital health records provide ready and remote access to medical and dental histories, and let clinicians evaluate records prior to a patient’s in-office examination.
- The use of intraoral cameras facilitates discussions with patients during treatment planning and helps encourage case acceptance.
- Benefits of digital radiography include reduced radiation exposure, electronic file management, and the ability to enhance and share radiographs electronically.
- The advent of three-dimensional cone beam computed tomography has afforded new advantages in clinical practice by facilitating treatment planning and providing intraoperative guidance for more complex procedures.
- Intraoral scanners can obtain anatomical information quickly and accurately. Scans can be linked to in-office design and milling system for “same day” restorations, or sent to laboratories for remote design and fabrication.8
- Emerging trends in mobile health, patient reporting and patient-based outcomes will further underscore the importance of digital dental technologies.
Digital radiographic imaging systems eliminate the burdens of emulsion-based chemistry and potential errors in film processing. This technology also helps reduce levels of ionizing radiation. A downside, however, is the capital expense of equipment. Other reported barriers include problems integrating digital imaging software with other office systems, the potential for technical errors, and the sizes and comfort of intraoral sensors.6 Advantages of digital imaging include electronic file management and the ability to enhance and share radiographs electronically. Maintaining digital images as part of electronic dental records is now recognized as central to optimal record keeping in dental practice. Furthermore, the proliferation of monitors in dental operatories permits immediate visualization of images that can be magnified and shared with the patient and clinical team.
The advent of three-dimensional (3D) imaging systems has afforded new advantages in clinical practice. Cone beam computed tomography (CBCT) provides important diagnostic information, and is especially useful for planning oral maxillofacial, implant and orthodontic treatment, as well as endodontic diagnosis. These images are often fundamental to communication and planning for complex, multistep dental procedures,7 and can support communication between health care providers and laboratory technicians. The Digital Imaging and Communications in Medicine — or DICOM — file format has been adopted for dentistry. This provides a common format that may be imported and reformatted by various software systems. While most patients will not require 3D imaging for routine dental care, such images may facilitate planning and provide intraoperative guidance for more complex procedures — including implant placement and third molar extractions.
SCANNING AND MILLING
The concept of digital crown manufacturing was introduced more than 30 years ago as a replacement for traditional clinical and laboratory procedures. Advanced optical technologies and greater computing power allow optical scanning, 3D imaging, and in-office fabrication of milled ceramic, hybrid and resin restorations within hours of tooth preparation.
Today’s intraoral scanning systems can obtain anatomical information quickly and accurately. Scans can be linked to an in-office design and milling system for “same day” restorations, or sent to laboratories for remote design and fabrication.8 Although it has not yet been determined how surface-scanned 3D images will be stored in a common file format, digital impression technology offers opportunities for clinicians to build more complete patient records that can be longitudinally evaluated.
As an alternative to conventional impressions, digital scans have proven to be accurate replacements for elastomeric materials in some situations. Scanners are commonly used to provide intracoronal (e.g., inlays and onlays) and extracoronal (e.g., crowns) restorations, small fixed dental prostheses (especially provisional restorations), and orthodontic appliances.9 Ongoing advances are focused on scanning partially or completely edentulous patients in order to facilitate digital clinical workflows that complement existing laboratory workflows for removable partial denture frameworks and complete dentures.
One factor that has contributed to the value of scanned impressions has been continuous improvement in milled materials. Milled lithium disilicate or zirconia restorations provide good marginal adaptation and esthetics. Additional developments in materials and in-office milling technologies will likely provide even greater clinical advantages. And if ceramic crowns are not indicated, metal crowns can be fabricated using the same design software. It is now possible to create most intracoronal and extracoronal restorations using the digital technology widely available in dental laboratories.10
Today’s digital dental technologies represent second- or third-generation products that are evolving with advances in computer processing and clinical demand.11 New emphasis on electronic health records and growing recognition of the value of a complete digital representation of patients’ intraoral conditions will continue to drive innovation. Emerging trends in mobile health, patient reporting and patient-based outcomes will further underscore the importance of adopting digital technologies. The value of digital information that includes 3D representation of oral conditions will become increasingly commonplace in practice, improving clinicians’ ability to manage patients and deliver care that leads to optimal outcomes.
In-Office and Lab-Based Design and Fabrication
Intraoral scanning is the front end of two clinical workflows. The first approach, known as “scan and mill,” involves impression scanning and in-office milling of restorations for delivery within a single appointment. The advantages of immediacy and elimination of provisional restorations are obvious. Disadvantages include the need to acquire the necessary skill set and time required to design and deliver high-quality milled restorations. The second approach is referred to as “scan only.” This involves scanning a preparation and sending the data to a laboratory, which designs and fabricates the restoration. Advantages of the scan-only workflow include leveraging laboratory expertise to create well-fitting and highly esthetic restorations, avoiding the capital expenditure and space required for computer aided design/computer aided manufacturing (CAD/CAM) equipment, and not devoting clinical time to designing and milling restorations in-office.
An alternative to intraoral scanning of prepared teeth is to obtain elastomeric impressions by pouring conventional stone models that are subsequently digitized by desktop scanners. This approach is widely used by dental laboratories, and many restorations are manufactured via this method. Specialty practices, such as orthodontic and prosthodontic offices, may use scanners to create digital files that can be stored instead of stone casts, input three-dimensional images into CAD/CAM software, and improve communications with labs and manufacturers.
- Myers-Wright N, Lamster IB. A new practice approach for oral health professionals. J Evid Based Dent Pract. 2016;16(Suppl):43–51.
- Advisory Committee on Training in Primary Care Medicine and Dentistry. Training Health Professionals in Community Settings During a Time of Transformation: Building and Learning in Integrated Systems of Care. Available at: hrsa.gov/advisorycommittees/ bhpradvisory/actpcmd/Reports/eleventhreport.pdf. Accessed February 1, 2017.
- Simmons K, Gibson S, White JM. Drivers advancing oral health in a large group dental practice organization. J Evid Based Dent Pract. 2016;16(Suppl):104–112.
- Christensen GJ. Important clinical uses for digital photography. J Am Dent Assoc. 2005;136:77–79.
- Coachman C, Paravina RD. Digitally enhanced esthetic dentistry — from treatment planning to quality control. J Esthet Restor Dent. 2016;28(Suppl 1):S3–S4.
- Ting NA, Broadbent JM, Duncan WJ. Dental radiography in New Zealand: digital versus film. N Z Dent J. 2013;109:107–114.
- Carter JB, Stone JD, Clark RS, Mercer JE. Applications of cone-beam computed tomography in oral and maxillofacial surgery: an overview of published indications and clinical usage in United States academic centers and oral and maxillofacial surgery practices. J Oral Maxillofac Surg. 2016;74:668–779.
- Batson ER, Cooper LF, Duqum I, Mendonça G. Clinical outcomes of three different crown systems with CAD/CAM technology. J Prosthet Dent. 2014;112:770–777.
- Rossini G, Parrini S, Castroflorio T, Deregibus A, Debernardi CL. Diagnostic accuracy and measurement sensitivity of digital models for orthodontic purposes: A systematic review. Am J Orthod Dentofacial Orthop. 2016;149:161–170.
- van Noort R The future of dental devices is digital. Dent Mater. 2012;28:3–12.
- Davidowitz G, Kotick PG. The use of CAD/CAM in dentistry. Dent Clin North Am. 2011;55:559–570.
The author has no commercial conflicts of interest to disclose.
Featured photo by OZGURDONMAZ/E+/GETTY IMAGES PLUS
From Decisions in Dentistry. March 2017;3(3):18,21–22.