Written by Gordon J. Christensen, DDS, MSD, PhD, and Paul Child Jr, DMD, CDT Monday, 07 February 2011 14:09
In recent years, dental practitioners have been overwhelmed with the claims made by manufacturers about many new and emerging technologies. As a result, there is significant confusion among practitioners about whether a new technology is better or even as acceptable and adequate as what was available in the past. We see thousands of dentists in our continuing education programs. Their many questions about manufacturer claims, their enthusiasm about new technologies accompanied with distrust of the claims, and the frequently observable blatant manufacturer over statement of the benefits of some technologies has led us to write this article expressing our thoughts on many of the new technologies.
The following information and suggestions about the usefulness of dental technologies are based on our constant observation of the global dental profession, evaluation of products for several decades, comments from users of the technologies, and our own personal experience with many of the technologies. It is intended to be a realistic guide to practitioners with questions as they plan to evaluate the products themselves.
WHY ARE DENTISTS CHANGING TO NEW TECHNOLOGIES?
We see the following reasons that are influencing practitioners to change from their current techniques and devices to new technologies:
- The true belief that the technology will benefit their practice and their patients. Advertisements and sales persons can be convincing, even though they may express only the benefits of new technology and downplay any negative aspects about the product. When considering a new technology, dentists should have a "buyer beware" attitude. Observe the ads, talk to practitioners who have used the concept, look for any independent reports on the product, and, if possible, obtain the product on a trial basis before purchasing it.
- Presence of a void in practice capability for certain procedures. Examples of this challenge are the many practices that have not changed to computerization of patient records. Often, these practices are unable to effectively communicate with third-party payers, other dentists, or even patients. In such examples, these dentists need to recognize that the state of the art has changed and that it is time for them to update to newer concepts.
- The "wow" factor for patients. Several of the new technologies are very interesting and exciting to patients. When a dentist has a technology that is attractive to patients, he or she is often considered by the patient to be up-to-date and progressive. In the recent recession, accompanied with the reported and obvious reduction in dentist income and activity, recruitment of new patients and stimulation of previous patients by any factor has been important. Some of the technologies to be discussed later can effectively be that stimulant.
- Dentist-perceived need for stimulation of personal enthusiasm for dental practice. We have seen this motive many times among mature "burned-out" dentists who have purchased, as an example, an in-office restoration milling machine, and have been reinvigorated to stay in practice instead of retiring. We, as practitioners (Dr. Christensen also has a background in psychology), have strong acceptance of this motivation. It is well known that any one of us should keep our life activities constantly changing at least 10% of the time to stay interested, active, and, frankly—alive.
A CRITIQUE OF CURRENT TECHNOLOGIES
We have elected to include only the technologies about which we receive the most questions. We fully understand that the following information will cause concern and disagreement on the part of some dentist and manufacturer readers. However, our intent is to assist some unknowing practitioners in their decision about specific dental technologies and to guide manufacturers in their development of new products or change in current ones. It is our hope to be fair and realistic to each technology and to those whose livelihood depends on its acceptance by the profession.
To make our opinions and conclusions easy to understand, we have placed at the heading of each technology one of the following ratings:
- Purchase ASAP
- Purchase when you can afford it, occasionally combined with the above rating
- See if it fits your practice needs (it is probably not for every dentist).
This article is not intended to be comprehensive or in-depth. That would require an entire course on each of the following topics. It is a stimulatory piece intended to motivate you to find more information on the popular technology topics that interest you.
CANCER DETECTION DEVICES
See if it Fits Your Practice Needs (It Should!)
What health practitioner, other than you and your dental hygienist, looks into patient mouths on a routine basis and has the knowledge to recognize any abnormalities? We have that responsibility! More than 30,000 oral cancers are detected annually in the United States, and more than 8,000 patients die of oral cancer. Most of the oral cancers are detected too late. Many dentists have purchased oral cancer detection devices for their practices. We encourage that concept. It is easily implemented by hygienists in routine recall appointments or by dentists if they prefer to do it. Dentists report relatively good patient acceptance to us, but only occasional third-party payment. Having helped save a few lives during our careers by detection of oral cancer, we can fully support the incorporation of oral cancer devices into all practices. The most used concepts are: Oral CDX (Oral CDX Laboratories), VELscope (LED Dental), and ViziLite Plus (Zila Pharmaceuticals), but numerous other companies currently are coming onto the market.
CARIES DIAGNOSTIC TECHNOLOGY
In general, radiographic interpretation of initial interproximal or occlusal carries is nearly impossible using the current generation of analog or digital radiographs. There are several devices on the market, including: Caries ID (DENTSPLY Midwest), DIAGNOdent (KaVo), LOGICON (Carestream Dental), Spectra (Air Techniques), and several others. These products are useful when understood and used properly.
Immediate attention by inventors and manufacturers is needed to eliminate this obvious void in technology!
CONE BEAM RADIOGRAPHY
See if it Fits Your Practice Needs and if so, Purchase as Soon as You Can Afford it
The newest dental specialty, oral and maxillofacial radiology, indicates the ADA's opinion on the importance of the area. The incorporation of cone beam (CB) images into dentistry will eventually change your practice significantly, especially in the areas of implant dentistry, surgical procedures, and endodontics. It is now in its infancy but growing rapidly. Since we incorporated CB into our prosthodontic practice a few years ago, it has been found to be indispensable. Because of the relatively high cost (~$100,000) of the devices, most dentists are not currently using CB. However, there are imaging centers being developed around the country. Vans containing CB devices are rotating around various communities on a scheduled appointment basis, and many group practices are buying CB devices. In other words, seek access to CB, and you can find it.
The advantages of this concept are well known. We predict that it will dominate the profession within 5 years. Cost of the devices is decreasing, and courses are being delivered to instruct dentists on CB image interpretation. Oral and maxillofacial radiologists are eager to assist in image interpretation.
In spite of the reluctance of some dentists to accept the fact that the concept is here, it will gradually become standard-of-care for some procedures. Get involved in some way!
In our considered opinion, root form dental implants are the most important change in dentistry since the introduction of high-speed tooth cutting with air turbines or electric handpieces. We have no reservation in suggesting that any surgically-oriented dentist should incorporate implant surgery into his/her practice after sufficient training/education in this area. (Dr. Christensen comments: Even though I am a prosthodontist, I have accomplished implant placement for 25 years. I have concluded, both from personal observations and from surveys of other restorative dentists and prosthodontists, that placement of implants in healthy patients with adequate bone is well within the average difficulty range of all dental procedures.) It should not be feared by general dentists. Additionally, we feel that all restorative-oriented dentists should include implant prosthodontics in their practices. Implant dentistry has virtually changed all of our treatment plans for those patients who fall into the approximately 178 million people in the United States who have at least one missing tooth and the 35 to 40 million people in the United States who are edentulous.
It is definitely the time to increase the use of implants in the specialties as well as in general dentistry. Take a good course, start on a few simple cases, and make this a part of your daily practice activity.
See if it Fits Your Practice Needs and if so, Purchase as Soon as You Can Afford it
Are these devices making better impressions than the popular polyvinylsiloxanes or polyethers? In our own studies (and those of others), the answer is YES! However, for somewhere between $20,000 and $30,000, are they appropriate for your practice at this time? Almost all of the users of the CEREC (Sirona Dental Systems), E4D (D4D Technologies), iTero (Cadent), or Lava Chairside Oral Scanner (C.O.S) (3M ESPE), are very satisfied with the digital impression concept and its effectiveness. Further advancements are coming constantly. We predict that some form of this concept will gradually dominate the impression marketplace. How long that will require is unknown, but we predict between 5 and 10 years.
If you don't have digital radiography, where have you been? The concept dominates analog radiography in most developed countries. The profession in the United States has been slow to accept it. There is no question that the advantages of digital radiography, including making immediate images, storage of images, ability to enlarge, colorize, or change contrast of images, educate patients, and several other positive characteristics, make digital radiography mandatory for up-to-date practices. The most popular are charge-coupled device and complementary metal oxide semiconductor devices because of the ability to make immediate images. However, phosphor plates are also adequate for some practices not doing implants or endodontics. Your local distributors can provide excellent information relative to the most acceptable and least repaired devices in your geographic area. There are many on the current market.
The main disadvantages are high cost and the presence of thick, rigid, difficult-to-use sensors. In our opinion, inventors need to devise thin, flexible, less expensive sensors immediately.
These devices have been in the profession since the late 1960s. Because the Borden air-rotor handpiece was invented in the United States, most American dentists have stayed with that concept. However, many other developed countries have accepted electric handpieces in preference over air turbine handpieces. The following comments reflect not only our own views, but also those of most electric handpiece users. Experienced electric handpiece users will choose not to be without low-speed electric handpieces. These handpieces are highly superior in torque (power) when compared to air-driven low-speed handpieces. This extra torque allows cutting dentures, splints, provisional restorations, stone or plaster, and other hard objects much faster than low-speed air handpieces. High-speed electric handpieces (~200,000 rpm) have 2 times the torque of most air turbine high-speed handpieces. Some dentists use them for all tooth cutting, while others use them only for finishing tooth preparations. In spite of the high cost of these systems, most dentists who have changed to electric handpieces are pleased with their decision. Brasseler USA and KaVo are the most popular companies, but there are excellent handpieces from many other companies.
IN-OFFICE MILLING OF RESTORATIONS, CAD/CAM
See if it Fits Your Practice Needs, and if so, Purchase as Soon as You Can Afford it
We have been involved with research on this concept for more than 20 years with the successful CEREC and for the last 3 years with the equally acceptable E4D. There is no question that the concept is viable, that both current devices work effectively, that the restorations serve in an equal or better manner than laboratory made ones, and that the overall concept can be cost effective. The question for practitioners is—does this concept fit your specific practice? Most purchasers of these expensive devices (~$130,000) are satisfied with their decision. However, some are not. We suggest that interested practitioners take a course on the concept from unbiased users who have practices similar to their own before making a decision to purchase. If your practice is primarily restorative, your restorations are mainly single units, you are accomplishing at least 15 to 20 indirect restorations per month, you have a competent and computer savvy staff, and you are willing to devote sufficient time to become competent with the concept, do it! If not, laboratory restorations are still the dominant indirect restorations. We predict that some practitioners incorporating this technology will be thrilled with the in-office milling concept, that some will elect to make digital impressions only with the devices and send the computer information to a lab for milling, and that some will have no interest at all.
We know and have proven that the in-office restoration milling concept works well for those who will take the time to properly integrate it into their practices!
See if it Fits Your Practice Needs
The "wow" value of laser is well known. Patients are attracted to the concept, probably due to the success of laser in ophthalmology. Where are we now with laser in dentistry? Diode lasers are the most popular laser wavelength in dentistry. There is no question that laser is useful for cutting soft tissue. However, it is much slower than the well-known, significantly less expensive, electrosurgery or radiosurgery. There is growing research for acceptance of laser in treatment of periodontal disease. Some practitioners claim significant success in this area. Cutting hard tissue with laser was overhyped by manufacturers when it was introduced, causing a backlash by some practitioners who purchased the expensive devices for this purpose and found disappointing results. However, at this time, some practitioners claim acceptable clinical use of the newer lasers for some hard tissue needs.
Dr. Christensen has been involved in some way with laser research and use for several decades. Dr. Child is currently conducting clinical research on many lasers. This technology resembles religion in its acceptance and lack of acceptance. Some practitioners have made lasers their main interest in the profession and support the concept strongly, while others call the entire concept "a technology looking for a use." Laser use in dentistry is still seeking acceptance by the ADA and the American Academy of Periodontology. We have searched the overall medical literature, and laser use is just as controversial in dentistry as it is in some other medical field specialties.
We sincerely hope that research on laser use for treatment of periodontal disease and for cutting hard tissue will continue to be positive. Such success will validate the presence of laser use in dentistry. If laser fits your practice and the needs of your patients, use it, but recognize the controversy that this technology has generated!
LIGHT CURING DEVICES
(Update Your Equipment)
Light-curing of resins has been used for more than 30 years and has evolved though several identifiable generations. Until the last few years, the only popular fast light concept was plasma arc, with the DenMat Sapphire being the most popular. As recently as 10 years ago, fast resin-based composite curing (3 to 5 seconds) was considered to be questionable. However, at last, this concept has been deemed to be acceptable. Fast resin curing saves time, effort, energy, and money. Some proven current fast curing lights recently identified by CLINICIANS REPORT to be excellent are: bluephase G2 (Ivoclar Vivadent), ART-L5 (Bonart), SmartLite Max (DENTSPLY Caulk), and VALO (Ultradent Products).
MAGNIFICATION, CLINICAL MICROSCOPES
See if it Fits Your Practice Needs
Currently, most dentists use loupes at about 2.5x for routine practice and about 4.0x when higher magnification is needed. This magnification provides an established, well-known, and well-accepted adjunct to practice. Most practitioners are satisfied with this level of magnification while operating.
In spite of the promoted and the proven real advantages of higher magnification, the use of clinical microscopes has had slow acceptance, except for use with endodontic procedures. The learning curve, cost of the devices, and some difficulty of use have impeded clinical microscope use for day-to-day eclectic dentistry.
Two major companies dominate the clinical microscope area: Global Surgical and Carl Zeiss. Both have strong advocates and both work very well.
A new concept, working from an image on a monitor, has been developed by MagnaVu. It requires a learning period, but offers the advantages of near normal posture, high magnification, and excellent depth of field. This new concept and clinical microscopes overall deserve your attention.
See if it Fits Your Practice Needs
We have evaluated numerous shade matching devices. The VITA Easyshade Compact (Vident) is the most popular. Some dentists use these devices with enthusiasm, especially those who have trouble determining the color of teeth or who are colorblind. Others use the devices as an augmentation to their visual color matching techniques. Most practitioners do not use these devices, in spite of their being available for several years. You may find this concept useful.
VIRTUAL IMPLANT TREATMENT PLANNING AND PLACEMENT
See if it Fits Your Practice Needs
The manufacturer development of this concept is related to 3-dimensional (3-D) imaging CB and conventional computed tomography scanning systems. This is another controversial subject, since it increases the cost, time involvement, radiation, and needed training for implant placement. Most implants are placed as singles, and most experienced surgical dentists have been placing implants long enough without 3-D images that they are comfortable without surgical guides. However, when placing multiple implants, there is some agreement that the guides are desirable. Many systems are available at significantly different costs, difficulty of use, and accuracy. Meta-analyses show that the accuracy of most guides is good, but that inaccuracies of nearly 1.0 mm both at implant entry and at the apex of the implant are average.
Continued research, improved simplicity, less cost, and better training/education for practitioners are needed.
We have discussed the technologies on which we receive the most questions. There are numerous others that are not included and on which we have research and opinions. The exclusion of those topics does not indicate their lack of importance.
If you were to buy all of the technologies that are currently advertised as being important, it would be financially stressful. In addition, you may not find that you would use all of them with equal enthusiasm. In our opinion, some new technologies are mandatory for current practice, while others are primarily elective. Only you can decide which technology is desirable to better treat your patients and make dentistry more enjoyable for you and your staff. Incorporation of the right new technology into your practice will excite you, your staff, and your patients, stimulate your interest in dentistry, and potentially provide higher quality dentistry. The money you spend on the technology of your choice will be well spent if you evaluate each concept carefully and thoroughly before buying it.
Additional evaluative information may be obtained on these topics by visiting cliniciansreport.org or calling CLINICIANS REPORT at (801) 226-2121.
Disclosure: Dr. Christensen reports no disclosures.
Disclosure: Dr. Child reports no disclosures.
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