To examine how new technology can enhance one’s practice, it is necessary to review some of the techniques and procedures currently used in dental offices. Computers and other high-technology devices will not solve problems if basic skills and systems are not in place. An old computer term is GIGO, or Garbage In Garbage Out. With that thought in mind, I will examine some of the recent advances in technology that can lead the dental practitioner to systems that will enable him or her to deliver better and more comprehensive dental care to patients.
Patient care and communication can be enhanced substantially by using several new technologies.
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TRADITIONAL NEW-PATIENT EXPERIENCE
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A good starting point is to examine the new-patient experience from the initial contact with the dental office through the examination and treatment-planning. I will review this in steps, and then re-examine the sequence using some new techniques.
Making an appointment.
Before a patient contacts an office, he or she does some initial research. This might involve asking colleagues, friends or family members for a referral, looking up names in a telephone book or responding to advertising. The prospective patient calls the dental office to inquire about setting up an appointment for an examination, a prophylaxis or a particular problem. An office staff member then asks a series of questions based on office policy. In many cases, the staff member also asks questions from a preprinted form; the forms vary, depending on whether the call is for an emergency or a routine examination. The staff member records the pertinent patient information on the form and sets up an appointment. He or she then files the paperwork by appointment date, alphabetically or by some other filing system for new patients.
Completing forms.
Some offices follow up this telephone call with a welcome letter, a brochure about the practice, and medical and dental history forms for the patient to fill out. These forms can be sent back to the office in a self-addressed stamped envelope or brought in at the time of the appointment. By receiving the forms ahead of seeing the patient, the dentist can review the information, which might be important in cases in which a patient needs cardiac- or orthopedic-related premedications or has medical issues that need to be discussed at the appointment. In addition, some insurance questions may need to be addressed, and it is best not to wait until the patient is in the office. One problem with this procedure, though, is that a high percentage of people forget to bring in their forms, forcing them to fill out another set in the dental office.
At the appointment, the dentist and staff members review the completed forms. Staff members at the front desk review financial policies with the patient; the dentist reviews the medical history, making notes on the forms. The dentist performs a visual examination, which usually is followed by a "charting" (that is, recording the patient’s oral condition in his or her dental record). This typically entails filling in a preprinted tooth chart—often with colored pencils— to represent dental conditions and writing notes to explain findings, such as shapes of restorations and evident pathology.
A dental hygienist or assistant then obtains a full series of radiographs or a panoramic radiograph with some bitewings. Once these are recorded and developed, the dentist explains the findings to the patient. He or she typically uses a number of aids to facilitate this, including a hand mirror, augmented by a dental mouth mirror that is used to show clinical findings to the patient. The dentist also shows the radiographs to the patient (sometimes with a magnifying glass) and points out problems not visible to the naked eye.
Dentists also can use models, books and brochures to point out similar problems as well as treatment options. Artistic practitioners often draw elaborate pictures of the patient’s condition and treatment options. He or she then writes the treatment plan in the dental record, or on a form that is brought to the front desk where further appointments are made and financial information is discussed.
In some cases, a patient may need a referral to another dental office. The dentist usually completes a small slip that has been provided by the specialist, and often gives the patient a radiograph, an explanatory note or both to bring along.
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TECHNOLOGY-ENHANCED NEW-PATIENT EXPERIENCE
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I will now look at this scenario in a digital office.1 The prospective patient still may ask family and friends for recommendations, but instead of receiving a telephone number only, he or she obtains an address for a Web site (often listed in telephone directories and print advertisements), which can explain the range of services and provide the hours and office location. However, many offices reject the idea of having a Web site, assuming that the patient will use a search engine to find the Web address, and prominent search-engine listings are complex and costly. Although this may be true, a Web site can serve as a resource for existing patients as well as an information package for new patients.
When a patient telephones the dental office, a staff member can supply the Web address if the patient does not already have it. The Web site also can be a portal for setting up appointments for new patients or for generating e-mail inquiries. If the office uses a referral service, the prospective patient can be directed to the Web site to see if this is the type of office for which he or she is looking.
When a new patient calls the dental office, a staff member can enter the demographic information directly into the practice management system instead of filling out a form by hand, which would require that the information be transferred later to a computer. The staff member also can enter the source of the referral and the appointment date and time.
The patient then can be directed to an online medical/dental history form or any other forms that the office wants completed. Of course, this eliminates the possibility of a lost or forgotten form at the first visit. If an online system is not feasible, the staff member can create a personalized letter, usually with one or two mouse clicks, and send history forms (with a self-addressed stamped envelope) the same day. The letter can include inquiries for any medical or insurance records that may be needed. All of these steps are recorded into the computerized system, which improves documentation and allows for easy follow-up.
Because of the requirements of the Health Insurance Portability and Accountability Act and patient confidentiality issues, the dental practice must be sure that online transactions—as well as the office network—are secure. Accomplishing this may be beyond the scope of many practices, and professional help might be required. If the office uses a wireless network, additional data security measures must be implemented.
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THE NEW INITIAL EXAMINATION
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When the patient arrives, a staff member can enter any information that is missing in the dental record. If the office is using completely digital records, any handwritten records and radiographs can be scanned into the system. To scan radiographs, however, the office needs a scanner with a transparency adapter. A full-bed adapter is desirable. These have a backlight of at least 8
x 11 inches, which allows copying of full series of radiographs in mounts, or panoramic radiographs, cephalographs or other large films. Software usually comes with these units, although excellent dental software programs are available that make scanning easy.
Completing forms.
If the office uses paper history forms, a staff member can scan them into the patient’s electronic dental record. Some offices have computers available for patients to complete the forms themselves. These can be anything from a simple workstation to a tablet personal computer that allows entries to be made with a stylus. This type of system also allows the capture of a digital signature, which may be useful for insurance purposes. A slightly more esoteric solution would be to have a Web-enabled computer in the waiting area, which would allow patients to complete the forms online.
Digital photography.
The visual clinical examination can be enhanced by taking digital photographs and closeups with an intraoral camera. A full-mouth series of photographs can be taken with the digital camera. These include full upper-arch and lower-arch images (with the help of mirrors), as well as photographs of the anterior teeth (naturally, to see the smile lines, and retracted, to see the supporting tissues). The dentist can take these digital photographs in occlusion and with the mouth open. Buccal and lingual photographs also can be taken.
The dentist or a staff member can transfer the photographs quickly from the digital camera to the computer in the treatment room using one of several methods depending on the camera. Some cameras require the removal of a digital image card, which is placed into a reader, while others have docking stations or outlets on the cameras that allow a direct transfer to the computer. As Bluetooth and other wireless technologies become available for use with digital cameras, this will introduce a new, simple transfer method.
The dentist can show these images to the patient, and new higher-resolution sensors in the cameras enable him or her to zoom in with remarkable clarity. The dentist uses an intraoral camera to show "live" images on the computer monitor to demonstrate conditions directly to the patient. In some situations, an intraoral camera provides a higher-resolution image than a digital camera, owing to its optics and the direct lighting. This higher-resolution image is helpful in evaluating internal and external fractures.
Electronic dental records.
The dentist or a staff member stores the images in the patient’s electronic record, or archives them using software such as Kodak EasyShare (Eastman Kodak, Rochester, N.Y.) or ThumbsPlus (Cerious Software, Charlotte, N.C.). A traditional charting still can be constructed, although the practice management software may have an electronic template that can be accessed on the screen or printed out if desired. With digital images, dentists may not need to write out the details of a condition because the photographs show the extent of the problems.
Voice recognition programs.
Some voice recognition programs perform quite well for recording information in dental records. Because dental charting requires the use of a limited number of words (such as tooth numbers, surfaces and periodontal depth), these programs—with their limited vocabulary—can be quite accurate. Despite advances in software and hardware, however, voice-generated clinical notes (which require a larger vocabulary) need a bit of editing. Some voice systems allow the construction of predetermined phrases (called macros) that allow the practitioner to use this technology, although in a modified form.
Digital radiography.
Two categories of sensors—direct and scanned—are available to obtain digital radiographs. Direct periapical sensors can be wired or wireless and allow the image to appear on the screen in seconds. Phosphor plates involve the use of a reusable, flexible digital sensor, which approximates the size of traditional radiographic film. This sensor is placed into an optical scanner, which "reads" the information on the sensor and forms the digital image.
Both of these systems enable the dentist to display the radiographs on the computer screen in various formats. The images can be magnified for easier viewing; they also can be enhanced and even corrected by the software. The operator can view several digital versions of the images and, in some cases, the software can read densities or make comparisons with previous radiographs to enhance the diagnostic capability. Once again, the patient can be better-educated, because the image is quite visible and the operator is able to expand it to several inches.
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PUTTING THE NEW IMAGES TO USE
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The digital photographs and radiographs that are stored electronically can be printed for other uses, such as sending copies to third parties (for example, insurance companies) and other dental offices that are unable to receive digital images, and providing them to patients if further discussion is needed or decisions need to be made (for example, for elective procedures such as cosmetic treatment). The dental staff can perform cosmetic transformations of the digital photographs using software in the office or outsource them to companies that perform a simulation of future treatment results. This is called "cosmetic imaging" and can be done with a variety of software programs that enable the practitioner to modify individual teeth in terms of size, shape and color, as well as alter multiple teeth. In addition, highly regarded practitioners and technicians have developed prefabricated "smile libraries" that allow a new smile to be inserted directly over the existing photographic image.
However, a warning is in order for practitioners contemplating the use of these imaging products. The practitioner must be able to deliver the end result that is shown to the patient. An uncomfortable situation can arise if the results do not live up to the patient’s expectations, which he or she may have derived from viewing a printed before-and-after simulation.
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NEW DIAGNOSTIC DEVICES
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Treatment planning also can be enhanced digitally with regard to new, conservative, minimally invasive restorative procedures. One device in particular, the DIAGNOdent (KaVo America, Lake Zurich, Ill.), has changed the diagnostic paradigm of many practices. This low-level laser fluorescence device enables the clinician to evaluate quantitatively the smaller "sticks" and "watches" that are common throughout the profession.2,3 Such early diagnosis enables the practitioner to use such approaches as microrotary instrumentation, air abrasion and laser technology along with newer, bonded resin-based composite restorations to help patients maintain more of their tooth structure.
Similarly, high-intensity lights for transillumination can be a helpful diagnostic tool. A unique device, Digital Imaging Fiber-Optic TransIllumination, or DIFOTI (EOS Electro-Optical Sciences, Irvington, N.Y.), incorporates illumination and video, allowing the practitioner to visualize the findings on a computer monitor. Several other high-technology devices can enhance the diagnostic capabilities of the practitioner as well. The DetecTar (Ultradent Products, South Jordan, Utah) uses a light-emiting diode to visualize and detect subgingival calculus, while the Perioscope (DentalView, Lake Forest, Calif.) is a highly illuminated microcamera lens that can peer into a periodontal pocket and magnify the area almost 50 times.4,5
It might appear that the digitally enhanced new-patient examination would require hours to assemble all of the necessary information. The fact is that because of the speed of digital radiography and the reduced amount of time spent calling out tooth conditions for the dental record, the process takes approximately the same time as it does in the traditional examination. Some extra minutes may be spent discussing the examination findings; however, a more comprehensive treatment plan probably will be the result.
Patient presentations.
Some technologically savvy practitioners might present the digital findings to patients in a more sophisticated manner. For example, PowerPoint (Microsoft, Redmond, Wash.) offers templates that allow easy insertion of the examination findings and perhaps the computer-generated simulated treatment expectations. Some offices even set up a consultation room with a liquid-crystal display projector with which to show this plan and then present it to the patient on a compact disc for him or her to take home.
Educational systems.
Even with such presentations, patients still may have questions. This is the point at which new-patient educational systems can be used. As stated above, the office may have a Web site to which the patient can be referred. If the treatment room has a computer with online access, this can be done immediately. In addition, several educational software programs that consist of multimedia modules can describe various procedures and technologies. These programs can take the place of the elaborate drawings, models, books and photographs that many offices use.
Some systems allow customization whereby the practitioner can insert his or her own images. These professionally created presentations can save a lot of time spent explaining basic procedures. Hygienists, for example, need only to open a module labeled sealants to inform a patient or parent of this commonly misunderstood, basic procedure.
In addition to these products, many professional resources are available to the general public on the World Wide Web. Procter & Gamble, for instance, has put together an excellent resource ("www.dentalcare.com") about dental health for patients and dental practitioners. Many other companies and individual practitioners have set up educational sections on their Web sites covering multiple procedures in formats that a layperson can understand.
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HIGH-TECHNOLOGY TREATMENT OPTIONS
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Computer aided-design/computer-aided manufacturing.
Once the treatment has begun, an array of new products and equipment can be used to enhance treatment.6 It is not the purpose of this article to extol or debate clinical benefits, superiority or ease of use, but some of the modalities deserve mention. Computer-aided design/computer-aided manufacturing, or CAD/CAM, has evolved within the past few years to create dental restorations. With more powerful processors available at lower costs, it is economically feasible to install such a device in a dental practice. The marginal integrity of the resulting restorations is on par with that of restorations produced in dental laboratories.
The nonclinical benefit is the time savings for patients and dentists, because the process can be completed in one visit. This also eliminates the need for impressions and temporary restorations, which can be a source of clinical problems; there also is a minor cost savings involved. Patients, for the most part, appreciate the fact that they do not have to return for subsequent appointments. New software and hardware are entering this area of dentistry, rapidly improving the process.
Dental laboratories also are beneficiaries of this technology. Wax-ups, copings and restorations can be created in a dental laboratory with great accuracy using laboratory CAD hardware and software, but, more importantly, greater strength from nonmetal materials can be achieved. New prestressed ceramics are made in solid blocks that are milled and shaped by the computer system to make single copings and bridge frameworks. Restorations are constructed with traditional porcelain or similar esthetic materials in the same manner as would be done with metal substructures. This can lead to durable, more esthetic restorations for patients. Some of these laboratory devices also can create metal bridge substructures and single units, thus eliminating any potential casting difficulties. Although this does not eliminate the need for a technician, it does allow the laboratory to maximize the output of one individual.
Shade matching.
New devices and software7 are available that have enhanced shade matching. Some industries have used expensive spectrophotometers or colorimeters to match paint colors for home and commercial applications, as well as for the auto industry. The transition to smaller, cost-effective and more accurate units has occurred, allowing quantitative information to be sent to the dental laboratory.
Color correction software programs also are available that equilibrate colors on digital photographs and on various computer monitors. The laboratory also can use shade-matching devices to check the shade of prostheses before returning them to the practitioner. Information such as shade can be transmitted electronically to the dental laboratory if both the practitioner and technician have the appropriate computer infrastructure in place. This opens up the possibility of sending other information (such as laboratory prescriptions and photographs) to the laboratories.
Transcend (Chestnut Hill, Mass.) has created TransLab and Dental Rx Online, which allow the dentist to enter a laboratory prescription online (including images) in a secure Web-based pathway. The company also has developed other secure online products for communication, such as TransNet. This program sets up essentially private online referral networks in which patient information can be shared securely in study groups or in individual consultations with medical and dental colleagues.
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COMMUNICATION WITH PEERS AND ONLINE JOURNALS
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One area in which the Internet has enhanced dental practice is online dental groups. Through these groups, dental professionals exchange information around the world, 24 hours a day.8 Compuserve had a dental group in the early 1990s, which was followed by the Internet Dental Forum (started by David Dodell, D.M.D., in Scottsdale, Ariz.). The Compuserve site is defunct, but the Internet Dental Forum allows dentists and other dental professionals to discuss dental ideas, cases, problems and other issues though an interactive e-mail and Web-based forum.
Often, these online forums enable practitioners to discuss information before it has become common knowledge. This allows a practitioner who may not have frequent contact with colleagues to have a resource as close as a computer keyboard. Other groups such as genR8TNext (Generation Next) and DentalTown have captured dental professionals, who have not only instant information resources, but also an avenue for professional camaraderie. Questions can be answered, in some cases more quickly and completely than would be possible with other research methods. Many of the foremost dental authorities have an online presence and are accessible to the members of these groups.
Many journals now are available online that allow access to peer-reviewed materials, such as The Journal of the American Dental Association and the Journal of Contemporary Dental Practice. Because most of these journals are searchable in their online formats, readers can retrieve specific information quickly, without the need to pore through stacks of hard-copy journals found in many offices.
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CONCLUSION
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As I have illustrated in this article, high technology goes far beyond having a computer at the front desk. Dental professionals can take several avenues to enhance the practice of dentistry. Although I have presented several ideas here, it is not necessary to put all of these concepts to use. Every practitioner has his or her own comfort level and can choose to pursue those areas that are in accordance with the practice’s philosophy. I hope that many of the points made here are analyzed fully and debated to benefit the future practice of dentistry.
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ABSTRACT
TRADITIONAL NEW-PATIENT...
