Simply stated, dental treatment would be virtually impossible without many technologies supporting it. Even the earliest dental treatment (tooth extraction) required creative thought by humans designing instruments to facilitate it. Many of the most clever, useful, and enduring dental technologies have originated in the minds of dentists, dental laboratory technicians, hygienists, and assistants to fill unmet clinical needs. In the current onrush of new technology competition, where are we now in 2018? Damon Adams, DDS, editor-in-chief of Dentistry Today, led a discussion with Rella Christensen, RDH, PhD, to find out.
What do you think is the most important new technology clinicians should consider adopting right away?
Dr. Christensen: I would name cone beam radiology, because it can reveal conditions missed consistently in the patient’s past examinations. These formerly undetected conditions could be important to the patient’s health and treatment priorities. Today, dentists have options. They can purchase their own cone beam equipment, or they can gain access through traveling mobile units, radiology labs, or colleagues who are already using this technology. It is important to realize this is a developing technology with differences in equipment offered by different companies. In addition, the expertise of a certified radiologist is necessary to interpret these new images and clinicians must upgrade their knowledge through coursework. I think the best way to get started is to take a course and then talk to colleagues already using cone beam in their practices to gain perspective on the advantages and limitations of the technology. Currently, the primary uses of cone beam are in endodontics and oral surgery, particularly implant surgery. Cone beam technology has not been adapted yet for dental caries diagnosis, but, theoretically, the possibility exists. Cone beam could show not only the location of caries lesions, but also the extent of these lesions by “slicing through” them. Clinicians have never had such an opportunity before. The limitations of cone beam might be start-up cost, a lack of space in the office for the equipment, and the learning curve necessary to interpret the images. However, I believe cone beam technology is here to stay, and the sooner dental clinicians learn to use it well, the better it will be for patients.
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| Figure 1. Light polymerized materials and a cordless curing light in action. | Figure 2. A scanning electron microscope for study of the clinical performance of dental materials. |
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| Figure 3. A clinical camera for recording and comparing the clinical performance of materials and treatments over time. | Figure 4. Instrumentation for measuring fluoride release from dental materials over time. |
What do you consider the most interesting emerging technologies?
Dr. Christensen: Three-dimensional printing and intraoral scanning come to my mind immediately, but this is a personal opinion that could differ by clinician and specialty. Both printing and intraoral scanning are in current use in a growing number of dental practices and laboratories across the United States, and both have the potential to improve patient treatment by improving accuracy, consistency, and delivery times of provisional restorations, and, eventually, fixed and removable restorations. Our lab tested the practicality of intraoral scanning 15 years ago in a blind comparison of full-contour molar crowns where 2 crowns each were fabricated by the same lab for the same preparations in a group of patients treated by 5 dentists. The dentists then selected the blinded crown they preferred for fit, form, and function. Interestingly, in all cases except one, the dentist selected the crown fabricated from the intraoral scan in preference to the crown fabricated from the conventional physical impression that he made. Back in 2004, when we compiled the results of this research, in addition to the work we had in progress with CEREC (Dentsply Sirona) intraoral scanning, we became convinced that scanning was the future and aimed our clinical research at CAD/CAM-produced monolithic restorations. Many don’t realize that it was CEREC that brought intraoral scanning into restorative dentistry. Although CEREC’s combination of intraoral scanning and milling was accepted slowly at first using the in-office fabrication approach, once commercial laboratories adopted CAD/CAM fabrication, a virtual revolution in materials, fabrication methods, and business models of dental laboratories and dental practices occurred, and it continues to this day. I believe we will see a similar pattern with printing. Right now, we are in the cautious beginning of the curve, but I believe this will be followed soon by an explosion of activity as printing equipment, the printing process, and the materials printed are improved. Right now, we seek upgrades in accuracy, resolution of detail, and elimination of chemical residuals released from the plastics printed. But I believe all of these challenges are surmountable. Watch and see!
You mentioned CAD/CAM. What are your thoughts on the future of CAD/CAM in-office and in-laboratory technologies for restoration fabrication?
Dr. Christensen: Well, it is obvious that CAD/CAM technology used in-office by the dentist and staff, and especially that which is used in commercial laboratories, has swept through the profession worldwide and just about eliminated technologies that had been used for many, many years, such as all-metal and PFM fixed prosthesis technologies, including lost wax casting, hand layering of porcelains, metal soldering, etc. However, I don’t think we can rely forever on fabrication methods like milling that use subtractive technology, unless we can find ways to use the tons of sludge waste it now generates daily worldwide. I have friends who are already setting up businesses that recycle the zirconia sludge generated in dental laboratories. However, I think future methods will be developed to print or cast zirconia slurries or, perhaps, other similar tooth-colored materials not yet introduced. But for now, CAD/CAM-generated, zirconia-based materials have taken over and reign supreme! The rapid acceptance of these 2 concepts, CAD/CAM and zirconia, has caused clinicians and researchers to scramble to quickly learn more about the advantages and limitations of the various zirconia as clinical use outstrips the knowledge base. Consider these critical areas where essential information is lacking: (a) Today, clinicians cannot advise patients concerning how or when a CAD/CAM-produced zirconia restoration might fail because this information is not yet known; (b) as yet, no one knows the clinical implications of the various oxide and ion additives now placed in zirconia to influence its translucence, color, and physical properties, yet thousands of these clinically unvalidated zirconia formulations are seated every day worldwide; and (c) increased wear of opposing dentition by some of the newer zirconia formulations has been observed recently in our clinical studies, but we do not know yet why this is occurring. The original BruxZir formulation (Glidewell Laboratories) introduced in 2009 has not shown this problem clinically. Our lab now has 8 years of definitive data from controlled clinical practice-based studies of BruxZir original solid zirconia and IPS e.max CAD lithium disilicate (Ivoclar Vivadent) full-contour molar crowns showing 100% and 95% survival, respectively, at 8 years with no abrasive wear of the opposing dentition. Although we have identified these 2 CAD/CAM-produced monolithic crown materials as excellent performers clinically, the competitive marketplace is trying to push past these 2 well-proven products and the clinical research is not keeping up with the clinical use. This can cause dentists and their patients to experience unforeseen problems. So, while we love to see technology move forward in leaps and bounds, there is a need to look for proof that newer is better before rushing into the newest concepts.
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| Figure 5. An anaerobe chamber for the culturing of oral microbes associated with dental caries, periodontal disease, and oral pathologies. | Figure 6. High-resolution replicas, fabricated to study the clinical status of tooth-colored fixed prostheses over time. |
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| Figure 7. Loupes and a head lamp, to enhance visual access necessary for precise work in treatment and research. | Figure 8. Soft-tissue and hard-tissue lasers, used for research of laser effects on tissues and microbes. |
In your opinion, which technologies are responsible for the most significant improvements in everyday patient care?
Dr. Christensen: Everyday basics like radiographs, local anesthetics, air rotor and electric handpieces, magnification, and hand instruments of many designs most immediately come to mind. Although these technologies are taken for granted today, they represented huge leaps forward when they were introduced. Today, when most people hear the word “technology,” their thoughts jump to the automated and/or software-driven devices that are entering the market at an ever-increasing pace. In dentistry, these have also resulted in important improvements in care. Consider products such as the newest apex locators, automated endodontic handpieces, ultrasonic devices for cleaning and disinfection of root canals, soft- and hard-tissue lasers, and business software, to mention just a few. Then there are the technologies that help patients better understand their oral problems and treatments, such as intraoral cameras, caries detectors, and patient education videos. All of these things mentioned have greatly improved patient care. As stated in the beginning of this discussion, dental treatment absolutely depends on, and would be impossible today without, a whole list of instruments, devices, equipment, and materials that add up to a large array of dental technologies. Sure, we can deliver patient care without some things I listed, like magnification, but when we use it, we can do a much better job or even see something important we might otherwise have missed. This is a good example of the way technology can support and improve delivery of care. Clinicians who learn to use loupes and head lamps generally feel uncomfortable and insecure if forced to return to unaided vision during a procedure. In our research in dental materials and dental caries, we simply cannot operate without magnification that includes loupes, head lamps, and operating microscopes. In fact, magnification has become the norm in some clinical areas today—for example, operating microscopes in endodontics.
Do you think technology will replace people in dental treatments?
Dr. Christensen: This is a question in which I would never say “never!” However, in the foreseeable future, people are still absolutely necessary to control, maintain, and repair the technology used for patient care. But for routine tasks in dental laboratories and clerical tasks in dental clinics and dental laboratories, I see that people already have been, or are in the process of being, replaced. From a business point of view, people are the most valuable asset and the most frustrating liability—and generally the largest expense. So, it is easy to see why the crosshairs of technology are focused on the exclusion of as many people as possible from multistep processes. However, people are difficult to replace when judgments involving human health are concerned. Here, intelligence and clinical experience, along with abstract concepts like empathy and sympathy, come into play, and humans still have the advantage in these areas.
Are there some urgently needed technologies not yet present?
Dr. Christensen: Absolutely yes! For the clever and enterprising of the world, there is plenty of opportunity. Today, there is a push worldwide to find ways to treat everyone, not just those educated to seek dental treatment and with the resources to pay for it. Innovative technology and automation will be essential to address this challenge. Considering just the sheer number of people worldwide never touched by a dental clinician in the past gives some perspective on the need for new ways to address dental health worldwide. For more than 40 years, our lab has sought help from companies and individuals around the world to develop a technology we can place and leave in the oral cavity to regulate pH shifts that initiate demineralization of tooth structure. It is a simple idea, but it calls for a complex solution—and we have yet to find anything that truly addresses the challenge. But here are some other long-overdue needs begging for solutions: (a) restorative materials and cements that respond 1:1 with surrounding tooth structure and chemically seal at the material-tooth interface—and stay sealed; (b) technologies that measure and monitor inflammation to help achieve more effective treatment of periodontitis; (c) instruments that “see” and display the microbes involved in periodontal disease and dental caries, giving their locations, concentrations, and perhaps even their genus and species; and (d) digital impression technologies that “see through” tissue and blood with resolutions useable for milling subgingival margins. I could list many more theoretically solvable problems where new technologies could move treatment beyond where we are now. There’s no doubt about the fact that there are still numerous unmet clinical needs.
As dentistry moves into more complex computer-based technologies, how can clinicians keep up?
Dr. Christensen: Good question! It can seem overwhelming to take on the number of new technologies. Keeping up involves not only costs for purchasing and maintenance, but also on-site expertise to operate the technology and interpret the data produced. I believe the best approach, wherever possible, is to try to share purchase and upkeep costs with colleagues. In the past, dentists have been known for their strong desire to be independent, but it appears to me that the future will force the need to work, act, and own in groups. Young people in many disciplines are now trained and required to work in teams. I think the increasing costs and complexity of operating future technologies will push hard toward groups working together. The challenge is to find the people who blend into a well-oiled group called a team. I believe the best approach to keeping up with the constant upgrades in hardware and software is to delegate. Develop a team of staff who are “specialists” in various specific technologies. Make it each specialist’s responsibility to know how to operate, update, and maintain/repair his or her technology—and reinforce and inspire with monetary and verbal rewards. The main thing is to avoid withdrawing and hoping to retire before your patients begin to seek care elsewhere because they perceive you as being behind the times. I have just reluctantly changed my primary care physician for this reason after relying on him for 40 years. But, today, he is missing things, and I am getting older and cannot chance too many “missed things.” Plan to keep up by getting together with your staff and colleagues and carefully choose something new each year and embrace the challenge to learn it. Then let patients know you have something new at your office and how it can help them. The idea is to make the advancing technologies work for you!
Rella, thanks so much for taking the time for this excellent update on technology that is based upon many years of experience and research in the dental field. I am confident that our readers, as well as I, have learned important information and insights from sharing your thoughts and advice with us.
Dr. Christensen currently leads TRAC Research Laboratory, which is devoted to clinical research in oral microbiology and dental restorative concepts. TRAC Research is part of the nonprofit educational Clinicians Report Foundation (formerly CRA), which she directed for 27 years. Throughout her career, she has taught at the under- and postgraduate levels, authored many research abstracts and reports, and received numerous honors. She has performed research within the practices of hundreds of dentists and their teams seeking the best patient treatments. She can be reached via email at rella@tracresearch.org.
Disclosures: Dr. Christensen reports no disclosures.
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