Are Dentists Using New Clinical Technology?

Ira Lamster DDS, MMSc, Editor-in-Chief, Fiona Collins BDS, MBA, MA, FPFA

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Are Dentists Using New Clinical Technology?

Recent and emerging technological advances offer the promise of dramatic improvements in how disease is diagnosed and treated. This is certainly the case for dentistry.

Technological advances related to dental diagnosis and treatment include but are not limited to digital imaging (digital intraoral radiography, 3D imaging and intra-oral scanners), computer assisted design/computer assisted manufacturing (CAD-CAM), oral cancer screening devices, and salivary diagnostics for the detection of oral and systemic disease. Two important issues to consider are whether the dental profession is utilizing new clinical technologies, including digital radiography and CAD/CAM technologies discussed below, and the reasons for adoption or lack of adoption by dental professionals.

Digital imaging

Digital radiography and imaging offers significant advantages compared to traditional techniques. These include ease of image acquisition, viewing, and storage; improved interprofessional communication; reduced radiation exposure/radiograph; and the ability to show patients enlarged images on a screen to help educate them about their oral health, areas of concern and care options.1Van Der Stelt P. Filmless imaging. The uses of digital radiography in dental practice. J Am Dent Assoc 2005;136:1379-87.,2Estai M, Kanagasingam Y, Huang B, Checker H, Steele L, Kruger E, Tennant M. The efficacy of remote screening for dental caries by midlevel dental providers using a mobile teledentistry model. Community Dent Oral Epidemiol 2016;44(5):435-41.,3Ting NA, Broadbent JM, Duncan WJ. Dental radiography in New Zealand: digital versus film. N Z Dent J 2013;109:107-14.,4Ahmad I. Digital dental photography. Part 2: Purposes and uses. Br Dent J 2009;206(9):459-64. By 2010, 75% of dental radiographs in France were digital, with adoption outpacing the United States and other countries.5Gart C, Zamanian K. Global trends in dental imaging: The rise of digital. Dental Tribune July 27, 2010. Available at: https://us.dental-tribune.com/news/global-trends-in-dental-imaging-the-rise-of-digital/This high level of adoption demonstrated the impact of healthcare reimbursement policies strongly favoring digital radiography. Adoption rates in other countries were slower, due to costs, practice norms, reimbursement and other factors.5Gart C, Zamanian K. Global trends in dental imaging: The rise of digital. Dental Tribune July 27, 2010. Available at: https://us.dental-tribune.com/news/global-trends-in-dental-imaging-the-rise-of-digital/
In New Zealand, a cross-sectional survey on digital radiography was conducted in 2012 with general dentists and specialists.3Ting NA, Broadbent JM, Duncan WJ. Dental radiography in New Zealand: digital versus film. N Z Dent J 2013;109:107-14. Fifty-eight percent of respondents were using digital radiography. Significantly more non-adopters described digital radiography as too expensive (45% vs 23% of adopters). Cost of acquisition was the most important factor for lack of adoption. Non-adopters also more frequently reported being satisfied with film radiography, the difficulty of integrating digital radiography with practice software, potential patient discomfort and diagnostic errors (Figure 1). Lack of knowledge was not a factor, nor the possibility of fraudulent image manipulation or privacy issues.3Ting NA, Broadbent JM, Duncan WJ. Dental radiography in New Zealand: digital versus film. N Z Dent J 2013;109:107-14.

6Wenzel A, Moystad A. Work flow with digital intraoral radiography: a systematic review. Acta Odontol Scand 2010;68:106-14.

Figure 1. Factors in adoption of digital radiography

 


Cost of acquisition was the most important factor for lack of adoption of digital radiography in a recent survey.

Cone beam computed tomography (CBCT) provides three-dimensional imaging that is primarily used for planning implant therapy and oral surgery, as well as in endodontics and orthodontics.7Cooper LF, Ludlow ME. The current impact of digital technology in prosthodontics. American College of Prosthodontists. Digital White Paper. Available at: https://www.prosthodontics.org/assets/1/7/Digital_White_Paper_r1.pdf.,8Pakchoian AJ. The use of cone beam in Private Dental Practices in the United States: Cost and Reporting Patterns" 2016; Master's Theses. 886.
http://digitalcommons.uconn.edu/gs_theses/886
In the United States, more than 5,000 CBCT are in use in dental schools, dental offices and imaging centers.8Pakchoian AJ. The use of cone beam in Private Dental Practices in the United States: Cost and Reporting Patterns" 2016; Master's Theses. 886. http://digitalcommons.uconn.edu/gs_theses/886 In response to one online survey, CBCT was present in 78% of academic and private practice settings.9Carter 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. Adoption rates for CBCT would be influenced by the type of services provided as it is not routinely required across disciplines, and there is a concern about overuse. There is also a shortage of qualified personnel to interpret CBCT scans.8Pakchoian AJ. The use of cone beam in Private Dental Practices in the United States: Cost and Reporting Patterns" 2016; Master's Theses. 886. http://digitalcommons.uconn.edu/gs_theses/886 Adoption is greater in large group vs individual practices, as this enables cost sharing.7Cooper LF, Ludlow ME. The current impact of digital technology in prosthodontics. American College of Prosthodontists. Digital White Paper. Available at: https://www.prosthodontics.org/assets/1/7/Digital_White_Paper_r1.pdf. In addition, reimbursement policy can influence the number of CBCT scans taken.10Zhang A, Brown LF, Monsour PA. Effects from changes to the Medicare Benefits Schedule in 2014 on cone beam computed tomography and panoramic radiography scans across Australia. J Med Imaging Radiat Oncol 2017;61(5):600-6.

CAD/CAM Technology

CAD/CAM technology is used for indirect restorations, digital dentures, implant components, surgical guides and orthodontic treatment. In comparison to traditional techniques, CAD/CAM offers improved workflow, productivity, optional same-day delivery of restorations through chairside milling, a high level of accuracy and reliability, and patient comfort may be improved.11Nejatidanesh F, Shakibamehr AH, Savabi O. Comparison of marginal and internal adaptation of CAD/CAM and conventional cement retained implant-supported single crowns. Implant Dent 2016;25:103-8.,12Chochlidakis KM, Papaspyridakos P, Geminiani A, Chen J-C, Feng IJ, Ercoli C. Digital versus conventional impressions for fixed prosthodontics: A systematic review and meta-analysis. J Prosthet Dent 2016;116:184-90.,13Rossini 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;149:161-70.
A 2016 report examined use of CAD-CAM by dentists in the United Kingdom.14Tran D, Nesbit M, Petridis H. Survey of UK dentists regarding the use of CAD/CAM technology. Br Dent J 2016;221:639-44.
Adoption was relatively limited, with 42% of respondents using CAD/CAM. Important reasons for adoption included quality improvement, keeping up with technology and reducing laboratory fees. The percentages of respondents citing these reasons and subsequent achievement of each goal were 64% vs 68%, 59% vs 69% and 33% vs 34%, respectively (Figure 2). Additional reasons for adoption included improved productivity and communication, and use as a marketing tool.
Important reasons reported in one survey for adoption of CAD/CAM included quality improvement, keeping up with technology and reducing laboratory fees.

Reasons given for not adopting CAD/CAM included cost (59%), lack of knowledge (18%), and the belief that CAD/CAM did not offer clinical benefits (26%) and/or resulted in inferior restorations (14%) (Figure 3).14Tran D, Nesbit M, Petridis H. Survey of UK dentists regarding the use of CAD/CAM technology. Br Dent J 2016;221:639-44. Dentists who mainly saw private patients versus those in the National Health Service were more likely to have adopted CAD/CAM technology (p˂0.001). Eighty-nine percent of respondents believed CAD/CAM utilization will increase.

Figure 2. Reasons for adoption of CAD/CAM and achievement of goal


Figure 3. Reasons given for not adopting CAD/CAM


Dental technicians in the United Kingdom and Ireland have also been surveyed, and 82% of respondents reporting use of CAD/CAM.15Blackwell E, Nesbit M, Petridis H. Survey on the use of CAD-CAM technology by UK and Irish dental technicians. Br Dent J 2017;222:689-93. Adopters reported improved quality assurance and predictability (45%), productivity (32%) and communication (15%). Among non-adopters, the most frequently cited reasons for not using CAD/CAM, other than working in a lab that did not have CAD/CAM, were cost (30%) and insufficient training (13%).

Barriers to Adoption

New technologies may offer significant advantages over traditional technologies. However, barriers to adoption reported by clinicians include cost of acquisition, difficulty of integration, the belief that they do not offer an improvement and/or may result in inferior results, and lack of training/knowledge. Formal training programs are required for current clinicians. Further, adoption of some technologies such as digital photography became more widespread as costs decreased. This new technology was still recognizable compared to what it replaced, and offered clear advantages for patient communication, recordkeeping
and interprofessional communication.
Additionally, higher adoption rates were reported by prosthodontists in educational settings versus those in private practice in a 2015 survey.7 For three-dimensional radiography, intraoral scanners and chairside milling, the corresponding adoption rates were 92% vs 56%, 69% vs 32%, and 50% vs 17%, respectively.7Cooper LF, Ludlow ME. The current impact of digital technology in prosthodontics. American College of Prosthodontists. Digital White Paper. Available at: https://www.prosthodontics.org/assets/1/7/Digital_White_Paper_r1.pdf. The cost of technology is, however, still a significant concern and a barrier to acquisition in educational settings.
Barriers to adoption of new technologies include cost, difficulty of integration, the belief that they offer no improvement, may result in inferior results, and lack of training/knowledge.

Dental Education and Training in New Technologies

In dental school clinics, reported technology adoption rates in 2015 were 91%, 85%, 58%, 30% and 3% for digital radiography, CBCT, CAD/CAM restorations, virtual surgical guides and implant placement, and digital dentures, respectively.16Brownstein SA, Murad A, Hunt RJ. Implementation of new technologies in U.S. dental school curricula. J Dent Educ 2015;79:259-64. Greater overall penetration of digital technology had occurred in preclinical courses.16Brownstein SA, Murad A, Hunt RJ. Implementation of new technologies in U.S. dental school curricula. J Dent Educ 2015;79:259-64. There is a need for dental schools to more fully incorporate education in new technology into the curriculum.17Fernandez MA, Nimmo A, Behar-Horenstein LS. Digital denture fabrication in pre- and postdoctoral education: a survey of U.S. dental schools. J Prosthodont 2016;25(1):83-90.,18Schweyen R, Beuer F, Bochskanl M, Hey J. Implementing a new curriculum for computer-assisted restorations in prosthetic dentistry. Eur J Dent Educ 2017. However, the ever-expanding amount of basic, pre-clinical and clinical information that needs to be included in the dental school curriculum presents a challenge.7Cooper LF, Ludlow ME. The current impact of digital technology in prosthodontics. American College of Prosthodontists. Digital White Paper. Available at: https://www.prosthodontics.org/assets/1/7/Digital_White_Paper_r1.pdf. Faculty and student responses to the use of CAD/CAM and other digital technologies in the educational setting are promising.
In a study in the pre-clinical setting, 64% of dentists and 88% of
students reported that digital impressions were more effective than traditional techniques.19Joda T, Lenherr P, Dedem P, Kovaltschuk I, Bragger U, Zitzmann NU. Time efficiency, difficulty, and operator's preference comparing digital and conventional implant impressions: A randomized controlled trial. Clin Oral Implants Res 2016. In other surveys, 90% of students found it enjoyable to use CAD, and 80% rated their CAD/CAM learning experience as good/excellent, with opportunities for instant and objective feedback based on quantitative evaluations.7Cooper LF, Ludlow ME. The current impact of digital technology in prosthodontics. American College of Prosthodontists. Digital White Paper. Available at: https://www.prosthodontics.org/assets/1/7/Digital_White_Paper_r1.pdf.,20Reifeis PE, Kirkup ML, Willis LH, Browning WD. Introducing CAD/CAM into a predoctoral dental curriculum: A case study. J Dent Ed 2014;78(10):1432-41.
A standardized digital dentistry curriculum has now been developed by the American College of Prosthodontists, and piloted in five US dental schools that are integrating it into the current curriculum.21Stoneybrook Happenings. School of Dental Medicine Pilots “Digital Dentistry” Curriculum. July 25, 2017. Available at: http://www.stonybrook.edu/happenings/sb_medicine/school-of-dental-medicine-pilots-digital-dentistry-curriculum/ This pilot program will include training on digital scanners, CAD/CAM, laboratory scanners, CBCT, caries detection and oral cancer screening devices.
There is a need for dental schools to more fully incorporate education on new technology into the curriculum.

Conclusions

Recently introduced and emerging technologies have been shown to improve treatment planning, productivity, accuracy, comfort, communication, patient education and recordkeeping. Digital technology also enables use of teledentistry, which can improve access to care for elderly patients and individuals in remote locations.2Estai M, Kanagasingam Y, Huang B, Checker H, Steele L, Kruger E, Tennant M. The efficacy of remote screening for dental caries by midlevel dental providers using a mobile teledentistry model. Community Dent Oral Epidemiol 2016;44(5):435-41. However, barriers to adoption remain, notably cost and lack of training. Formal training is required to increase adoption of technologies that benefit providers and patients. Paradoxically, it is also anticipated that emerging and currently envisioned technologies will reduce the need for dentists in the long term,22Milgrom PM, Horst JA. The effect of new oral care technologies on the need for dentists in 2040. J Dent Educ 2017;81:eS126-eS132. creating a structural challenge. At the same time, salivary diagnostics offers dentists an opportunity, albeit challenging, to expand clinical practice using new technologies for point-of-care/diagnostic testing for oral and systemic disease.23Jacobson JJ. Is dentistry going to get into the salivary diagnostics game or watch from the sidelines? Todays FDA 2013;25:26-7,29-33.

In conclusion, new technologies represent a paradigm shift for dentistry and will require significant resources, training and adaptation. They are also an opportunity to improve patient care and outcomes.

References

  • 1.Van Der Stelt P. Filmless imaging. The uses of digital radiography in dental practice. J Am Dent Assoc 2005;136:1379-87.
  • 2.Estai M, Kanagasingam Y, Huang B, Checker H, Steele L, Kruger E, Tennant M. The efficacy of remote screening for dental caries by midlevel dental providers using a mobile teledentistry model. Community Dent Oral Epidemiol 2016;44(5):435-41.
  • 3.Ting NA, Broadbent JM, Duncan WJ. Dental radiography in New Zealand: digital versus film. N Z Dent J 2013;109:107-14.
  • 4.Ahmad I. Digital dental photography. Part 2: Purposes and uses. Br Dent J 2009;206(9):459-64.
  • 5.Gart C, Zamanian K. Global trends in dental imaging: The rise of digital. Dental Tribune July 27, 2010. Available at: https://us.dental-tribune.com/news/global-trends-in-dental-imaging-the-rise-of-digital/
  • 6.Wenzel A, Moystad A. Work flow with digital intraoral radiography: a systematic review. Acta Odontol Scand 2010;68:106-14.
  • 7.Cooper LF, Ludlow ME. The current impact of digital technology in prosthodontics. American College of Prosthodontists. Digital White Paper. Available at: https://www.prosthodontics.org/assets/1/7/Digital_White_Paper_r1.pdf.
  • 8.Pakchoian AJ. The use of cone beam in Private Dental Practices in the United States: Cost and Reporting Patterns" 2016; Master's Theses. 886.
    http://digitalcommons.uconn.edu/gs_theses/886
  • 9.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.
  • 10.Zhang A, Brown LF, Monsour PA. Effects from changes to the Medicare Benefits Schedule in 2014 on cone beam computed tomography and panoramic radiography scans across Australia. J Med Imaging Radiat Oncol 2017;61(5):600-6.
  • 11.Nejatidanesh F, Shakibamehr AH, Savabi O. Comparison of marginal and internal adaptation of CAD/CAM and conventional cement retained implant-supported single crowns. Implant Dent 2016;25:103-8.
  • 12.Chochlidakis KM, Papaspyridakos P, Geminiani A, Chen J-C, Feng IJ, Ercoli C. Digital versus conventional impressions for fixed prosthodontics: A systematic review and meta-analysis. J Prosthet Dent 2016;116:184-90.
  • 13.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;149:161-70.
  • 14.Tran D, Nesbit M, Petridis H. Survey of UK dentists regarding the use of CAD/CAM technology. Br Dent J 2016;221:639-44.
  • 15.Blackwell E, Nesbit M, Petridis H. Survey on the use of CAD-CAM technology by UK and Irish dental technicians. Br Dent J 2017;222:689-93.
  • 16.Brownstein SA, Murad A, Hunt RJ. Implementation of new technologies in U.S. dental school curricula. J Dent Educ 2015;79:259-64.
  • 17.Fernandez MA, Nimmo A, Behar-Horenstein LS. Digital denture fabrication in pre- and postdoctoral education: a survey of U.S. dental schools. J Prosthodont 2016;25(1):83-90.
  • 18.Schweyen R, Beuer F, Bochskanl M, Hey J. Implementing a new curriculum for computer-assisted restorations in prosthetic dentistry. Eur J Dent Educ 2017.
  • 19.Joda T, Lenherr P, Dedem P, Kovaltschuk I, Bragger U, Zitzmann NU. Time efficiency, difficulty, and operator's preference comparing digital and conventional implant impressions: A randomized controlled trial. Clin Oral Implants Res 2016.
  • 20.Reifeis PE, Kirkup ML, Willis LH, Browning WD. Introducing CAD/CAM into a predoctoral dental curriculum: A case study. J Dent Ed 2014;78(10):1432-41.
  • 21.Stoneybrook Happenings. School of Dental Medicine Pilots “Digital Dentistry” Curriculum. July 25, 2017. Available at: http://www.stonybrook.edu/happenings/sb_medicine/school-of-dental-medicine-pilots-digital-dentistry-curriculum/
  • 22.Milgrom PM, Horst JA. The effect of new oral care technologies on the need for dentists in 2040. J Dent Educ 2017;81:eS126-eS132.
  • 23.Jacobson JJ. Is dentistry going to get into the salivary diagnostics game or watch from the sidelines? Todays FDA 2013;25:26-7,29-33.