High-tech dentistry
What is necessary and what is not
Gordon J. Christensen, DDS, MSD, PhD
You are faced with ads and promotions for high-tech dental concepts in every journal you read and in most of the continuing education courses you attend. If you were to incorporate all of these concepts into your practice, it is doubtful that you could afford to practice. Which of the high-tech concepts are mandatory? Which are desirable but not absolutely necessary, and which are mainly hype? The answers to these questions probably are different for each dentist.
This article provides my observations about the high-tech concepts available, based on dentist-user responses in my continuing education audiences, opinions of dental retailers and clinical research reports. I describe the state of the art of each high-tech concept and make observations concerning the profession’s acceptance of each concept. As each of the high-tech concepts evolves and matures, the answers to the questions undoubtedly will change.
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AIR ABRASION
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The technique of cutting tooth structure with aluminum-oxide particles has been used for several decades.1,2 Many practitioners bought air-abrasion tooth-cutting devices and incorporated them into practice. However, the debris created by the airborne aluminum-oxide particles was disagreeable to most dentists, and especially to personnel who had to clean the offices. As a result, many air-abrasion devices were retired to closets, and practitioners went back to preparing teeth with standard air rotor or electric handpieces. Several manufacturers ceased making the devices because of reduced interest among practitioners.
Some dentists continue to use air abrasion for several clinical situations, including pediatric restorative procedures; preparing small Class I, III and V cavity preparations in adults; and making tooth preparations without anesthesia in patients who cannot tolerate medications.
The air-abrasion concept has been modified recently to include spraying water with the aluminum oxide particles. I discuss this technology, named "hydroabrasion," later in this column. In spite of the debris caused by air-abrasion tooth cutting, it is a valuable, elective concept for those who want to reduce the use of rotary cutting instruments and provide relatively pain-free tooth cutting without anesthesia for some procedures.
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BLEACHING LIGHT
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There has been an enormous amount of hype about using lights to enhance tooth bleaching when using different concentrations of hydrogen peroxide. Continued clinical observation of this bleaching concept has shown that at the initial bleaching appointment, the teeth bleached with hydrogen peroxide and a light appear to be somewhat lighter than teeth on which only hydrogen peroxide was used. The slight difference in tooth color observed as a result of bleaching with lights and hydrogen peroxide versus bleaching with hydrogen peroxide alone appears to be temporary and caused by the light’s dehydration and heating of the teeth.3,4 After a few days to weeks, there appears to be no significant shade difference between teeth bleached with lights and those bleached without lights.
Although research varies as to the effectiveness of bleaching using lights, many of the lights used for in-office bleaching appear to be primarily a psychological factor for the patient.
All of us await a truly effective, fast and nonsensitizing method of whitening teeth. Until that appears, at-home bleaching still is the most popular and predictable method used by most dentists.
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CARIES DETECTION DEVICE
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DiagnoDENT (Kavo, Lake Zurich) is probably the most well-known device for determining whether initial carious lesions are present in Class I or V locations. Much has been published about this device, and there have been both positive and negative reports regarding its effectiveness.5–8 On the basis of polls I have taken in my various continuing education courses, a significant portion of dentists use the device.
If stain and calculus are removed from the teeth before using the DiagnoDENT, and appropriate clinical judgment is exercised to determine if restorative dentistry should be accomplished, the DiagnoDENT is a useful concept. It is both helpful to dentists and a good educational concept for patients. However, several dentists have been challenged by third-party payment companies and patients for alleged overtreatment when making decisions based solely on the numerical readings of the device. The DiagnoDENT is a useful device. Other concepts to detect initial dental caries in addition to the DiagnoDENT and radiographs are needed immediately.
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IN-OFFICE COMPUTER-AIDED DESIGN/COMPUTER-AIDED MANUFACTURING
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The CEREC in-office restoration milling device (Sirona Dental Systems, Bensheim, Germany, marketed by Patterson Dental, St. Paul, Minn.) now is in its 20th year of development and use.9,10 A significant number of dentists have purchased the device. It is functioning well, and the current fourth-generation unit is producing simple restorations as good as or better than laboratory-made restorations. Although the concept is expensive for dentists and the learning time is significant, with some exceptions, practitioners who have purchased the CEREC device offer positive reports about it. Dentists who are not reluctant to learn computer programs, who like the image of being up-to-date and who do primarily single-tooth restorative dentistry should consider in-office milling of indirect restorations. Soon, Sullivan-Schein (West Allis, Wis.) will market a competitive device called Evolution4D.
All of us await a truly effective, fast and nonsensitizing method of whitening teeth. Until that appears, at-home bleaching still is the most popular and predictable method used by most dentists.
Although the cost associated with in-office restoration milling devices is high, the lack of laboratory cost makes the concept financially acceptable for those who produce a significant number of the restorations routinely.
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DIGITAL PHOTOGRAPHY
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Numerous companies are producing and marketing digital cameras and accessories designed especially for dental use. Making digital photographs and using them for patient education, as well as filing them in electronic patient records for future reference and third-party use, are significant practice-building and administration concepts. Digital photographs can be modified by using readily available photograph editing software (such as Adobe Photoshop, Adobe Systems, San Jose, Calif.). When digital photographs are modified to demonstrate possible changes in patients’ appearance, treatment plan acceptance is increased and patients are educated more easily about their treatment. This concept is one of the most indispensable of all of the high-tech choices.11
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DIGITAL RADIOGRAPHY
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Although digital radiography continues to evolve and the devices are expensive, it is clear that the technology soon will dominate dental radiography.7 The advantages of immediate image observation, image storage, image transfer by electronic means and the ability to enhance images make most users of digital radiography pleased that they have changed from conventional radiography to digital. It is just a matter of time until digital radiography is expected of all dental practitioners. I suggest changing to digital radiography as soon as possible.
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ELECTRIC HANDPIECES
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The electric handpiece concept is not new and, in many developed countries, electric handpieces have been used instead of air rotors for several decades.13–15 Practitioners agree that low-speed electric handpieces are highly superior to air-driven low-speed handpieces, because of their increased torque (power) and higher speed compared with air-driven low-speed handpieces. When compared with air rotors, high-speed electric handpieces produce less noise, have twice the torque and have precision cutting ability. Although less than one-half of American dentists attending my continuing education courses have changed to electric handpieces, the trend toward the electric units is obvious and should be encouraged.
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HYDROABRASION
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Previously, I discussed tooth cutting with air abrasion. Hydroabrasion is similar in that it, too, involves the use of aluminum oxide particles, but it adds a water spray to the cutting process. Hydroabrasion eliminates the objectionable dust created by air abrasion; however, it still produces a muddy residue that must be evacuated. Although used by only a small percentage of dentists, hydroabrasion appears to be a promising and useful elective concept for some clinical situations (such as small cavity preparations and preventive resin-based composite restorations).
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IN-OPERATORY COMPUTERS
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Computers with easily viewed monitors help the dental team access schedules and patient records. Having the monitor placed in a location that is easy for patient viewing makes the in-operatory computer an invaluable tool for patient-education sessions. Many software systems are available, and they vary significantly in usefulness and cost. Careful evaluation of practice needs helps in selecting the correct system. One of the most important high-tech concepts a practitioner can consider is installing a computer in every operatory.
One of the most important high-tech concepts a practitioner can consider is installing a computer in every operatory.
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INTRAORAL TELEVISION
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Because of the decreasing resolution of intraoral cameras resulting from the perceived necessity to reduce cost, the resulting intraoral television images are acceptable primarily for patient education and not for documentation. I suggest that an intraoral television scanning of each patient’s mouth should be accomplished by a staff member at each recall appointment.16 The findings should be recorded and the patient education continued at each subsequent recall appointment concerning the previously observed needs. Intraoral television is highly useful for patient education, and most dentists use this concept.
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LASER
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Controversy abounds in the laser area. A small but growing percentage of dentists use lasers. Some practitioners are satisfied with their laser purchase, while others are not and have returned their lasers to their manufacturers. Research regarding the effectiveness of lasers in soft-tissue treatment is largely positive but also contradictory concerning tissue response, healing time, healing characteristics and overall effectiveness of the devices. Soft-tissue lasers have many strong advocates and some detractors. Most dentists continue to use electrosurgery instead of lasers for soft-tissue surgery.
Most users have stated that hard-tissue lasers are slow and imprecise. However, some dentists strongly support their opinions that hard-tissue lasers are highly valuable, both clinically and as a concept that attracts patients. Dentists know well that laser use in health care is desirable to patients, in light of the popularity of laser applications such as eye treatment and hair removal.
Dental political organizations have been slow to accept the potential usefulness of lasers for both hard- and soft-tissue applications and to promote them.
It appears that dental lasers are an elective high-tech item. Future developments, continued education about clinical use and viable research will further validate the usefulness of dental lasers.
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LIGHT-EMITTING DIODE CURING LIGHT
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Light-emitting diode (LED) lights used for resin curing are working well, and most dentists have purchased them.11 Their ease of use and ergonomic characteristics have made them more desirable than standard halogen lights, but they are not mandatory items. It appears that further evolution of LED curing lights will make them faster and more powerful. Plasma arc lights and one halogen light (Swiss Master Light, Patterson Dental Supply) still are faster than the current generation of five- to 10-second LED curing lights.
LED curing lights still are in an evolutionary stage, and further advancements are forthcoming.
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MICROSCOPE
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Most general dentists and specialists use magnifying loupes for operating and find them to be an important adjunct to high-quality clinical dentistry. Moving beyond loupes, many endodontists have accepted the use of clinical microscopes, and they find that microscope use increases their ability to provide high-quality endodontic treatment. The restricted operating field of treatment in endodontic therapy has made the microscope especially useful for this area of dentistry. A few clinicians in other areas of dentistry have attempted to stimulate use of clinical microscopes in their specific areas but, to date, acceptance of microscopes in dentistry outside of endodontics has been minimal.
Use of a clinical microscope certainly improves vision and allows observation of the operating field better than magnifying loupes. After a significant learning and adjustment period, clinicians can use a clinical microscope for some areas of clinical dentistry.18 A clinical microscope appears to be a desirable elective item.
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ORTHODONTIC TOOTH MOVEMENT
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In recent years, conservative, planned movement of teeth, as directed by computerized approximation of movement required and effected by a series of carefully planned trays, has become popular. The most popular system, Invisalign (Align Technology, Santa Clara, Calif.), continues to grow in acceptance, and other companies are now entering the market. Orthodontic experts state that only some types of malocclusions can be treated by these concepts. General dentists, pediatric dentists or orthodontists interested in this concept are able to select and treat some patients after attending appropriate continuing education courses. Patients appreciate the ability to have their teeth moved without the objectionable appearance of wires and brackets on them, and it is apparent that this concept will continue to grow in acceptance.
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COMPUTERIZED SHADE SELECTION
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Selecting the color for restorations has always been a significant challenge. Most dentists use a shade guide, combined with their own clinical judgment. Taking clinical digital photographs of the clinical situation and e-mailing the images to the laboratory or printing the images and sending them to the laboratory has become a widely used process in recent years. This photographic concept is useful and simple.
Several automated shade determination devices are available. Although some dentists use shade selection devices with success, these devices have not become highly popular among practitioners, in spite of their usefulness. Cost and a significant learning period for some of the devices have been impediments. Some shade selection devices are relatively simple, while others require several steps for color determination. Shade selection devices appear to be a useful elective high-tech item.
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SUMMARY
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Many new high-tech concepts and devices for dentistry have been introduced in recent years, and corresponding advertisements are predominant throughout the dental profession. Most high-tech devices and concepts are useful, some more than others. It would be difficult and costly to incorporate into dental practice every new technology that comes out on the market. It is common knowledge among most dentists that some dental procedures can be accomplished faster, easier and better with well-known, time-proven techniques, whereas other tasks are better accomplished with today’s newest technologies. Dentists must weigh technology’s perceived value to patients, as well as the relative efficiency of clinical techniques accomplished by conventional versus high-tech concepts when deciding whether to incorporate technology into their practices. This article has expressed my opinions about various high-tech concepts as I perceive them, and from my experience as I see them being accepted and used by the practicing profession.
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FOOTNOTES
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Dr. Christensen is the director, Practical Clinical Courses, and co-founder and senior consultant, CRA Foundation, 3707 N. Canyon Road, Suite 3D, Provo, Utah 84604. Address reprint requests to Dr. Christensen.
The views expressed are those of the author and do not necessarily reflect the opinions or official policies of the American Dental Association.
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REFERENCES
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- Christensen GJ. Cavity preparation: cutting or abrasion? JADA 1996;127:1651–4.
- Atkinson DR, Cobb CM, Killoy WJ. The effect of an air-powder abrasive system on in vitro root surfaces. J Periodontol 1984; 55(1):13–8.[Medline]
- Christensen GJ. Are snow-white teeth that desirable? JADA 2005;136:933–5.
- Hein DK, Ploeger BJ, Hartup JK, Wagstaff RS, Palmer TM, Hansen LD. In-office vital tooth bleaching: what do lights add? Compend Contin Educ Dent 2003;24(4A): 340–52.[Medline]
- Christensen GJ. Dental radiographs and caries: a challenge. JADA 1996;127:792–3.
- Hamilton JC, Gregory WA, Valentine JB. DIAGNOdent measurements and correlation with the depth and volume of minimally invasive cavity preparations. Oper Dent 2006; 31(3):291–6.[Medline]
- Ricketts D. The eyes have it: how good is DIAGNOdent at detecting caries? Evid Based Dent 2005;6(3):64–5.[Medline]
- Haak R, Wicht MJ. Caries detection and quantification with DIAGNOdent: prospects for occlusal and root caries? Int J Comput Dent 2004;7(4):347–58.[Medline]
- Christensen GJ. Computerized restorative dentistry: state of the art. JADA 2001; 132:1301–3.
- Christensen GJ. Is now the time to purchase an in-office CAD-CAM device? JADA 2006;137:235–8.
- Christensen GJ. Important clinical uses for digital photography. JADA 2005;135:77–9.
- Christensen GJ. Why switch to digital radiographs? JADA 2004;135:1437–9.
- Christensen GJ. The high-speed hand-piece dilemma. JADA 1999;130:1371–3.
- Christensen GJ. Are electric handpieces an improvement? JADA 2002;133:1433–4.
- Eikenberg SL. Comparison of the cutting efficiencies of electric motor and air turbine dental handpieces. Gen Dent 2001;49(2):199–204.[Medline]
- Christensen GJ. Improving treatment plan acceptance using diagnostic data collection by dental staff. JADA 1999;130:1629–31.
- Christensen GJ. The curing light dilemma. JADA 2002;133:1433–4.
- Christensen GJ. Magnification in dentistry: useful too or another gimmick? JADA 2003;134:1647–50.
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AIR ABRASION
BLEACHING LIGHT
