New Technologies Shape the Future of Dentistry

Paul Feuerstein, DMD (Can you identify the symbols on his tie?)

Our editor-in-chief, Dr. Damon Adams, interviews our esteemed technology editor, Paul Feuerstein, DMD, on matters related to technology and other topics of interest.

As you see it, what are the 3 newly introduced top technologies that are the most mind-bending and could have the greatest impact on today’s modern practice?
Dr. Feuerstein: The obvious answers are 3-D imaging, digital impressions, and CAD/CAM restorations, and the merger of these technologies. All 3 have had a direct impact on the everyday practice, with the most notable being the robust CAD/CAM res­torations made from lithium disilicate, zirconia, and several polymer ceramics. The rapid conversion from PFM to all-ceramic materials has been nothing short of re­markable. Despite the fact that only a fairly small percentage of dentists are using digital impression technology at this point in time, and still fewer are using cone beam computed tomography (CBCT) technology, the laboratories are digitizing the traditional impressions and models, allowing every clinician the ability to practice employing a digital workflow. The bottom line is that, even for many clinicians who may think they are not digital, they actually are, at least in part.

Laboratory technician skills have been changing from working with the traditional wax and plaster to the use of a mouse, trackball, and joystick. This is giving a push to clinicians to use digital impression scanning technology so that the workflow starts directly at the dental chair. When a traditional physical impression is taken, all dentists have a prayer they say while holding the tray or while the patient is closed on the material. “I sure hope the margins come out!” or “I hope there are no pulls or distortions!” etc. And, when the physical impression is removed from the mouth, there is usually a deep breath, an examination of the preps, and finally a sigh of relief (or perhaps an utterance of something the patient should not hear). In a tough case, or a touchy patient, there are even cardiac palpitations. Digital impression technology removes this angst. In the old computer days, we talked of “what you see is what you get” (WYSIWYG); you know immediately if the digital impression is correct as you are seeing it 20-plus times natural size on the screen. If part of the impression doesn’t look right, or perhaps you see a slight prep error, the digital impression systems allow you to fix these issues in the mouth and then to quickly rescan the prep without retaking the entire impression. When you are satisfied with the result, hit the “send“ button and the laboratory team is ready to start their work immediately. If the office has an in-house milling system, things happen even more quickly. Sending a digital impression to the lab team also eliminates the possibility of cases lost or damaged while in transit, and, of course, there is no shipping fee. Taking this a step further, in many cases, your lab team may not need a model, representing another reduction in the overall lab fee.

Digital systems continue to be even more interesting with the addition of 3-D CBCT. It would take pages to go over the diagnostic benefits of this technology, but suffice it to say that every practitioner will see a need for a patient scan several times a week. New technology allows the practitioner to scan only the small area of interest instead of the full mouth. There is a financial and space requirement for these devices, so some offices will partner with others, perhaps referring patients to specialists who may have the technology or work with imaging centers that are either brick and mortar or even mobile. The point is that this technology is readily and currently available to every practitioner. Focusing for the moment on the digital impres­sion/restoration theme, CBCT technology is invaluable in diagnosing and treatment planning implant restorations. Using specialized software, the dentist can plan for optimal success by placing an implant in the most predictable area and in the best available position. Using reconstructed, easy-to-visualize virtual models from these units, a case can be planned in what almost looks like a video game. Then, with the merging of an intraoral digital impression, the planned restoration can be placed in the ideal position and the implant(s) aligned in the correct path and angulation. This all but eliminates age-old problems of a restorative dentist having to place a crown with an oddly angled abutment and a screw coming out of the facial—something many of us have seen. In addition, the software allows for the fabrication of a “surgical guide” that looks like a bruxing appliance with holes and sleeves which direct the implant drills in exactly the place, direction, and depth as calculated by the software. This can, in most cases, eliminate flaps, sutures, and other surgical procedures, providing a better and less traumatic patient experience, often with faster healing. I will be going into more depth on these processes in future issues of Dentistry Today.

Trying out new aseptic low-tech bib holders. (Photo courtesy of Dux Dental.)	The first 4 intraoral scanning devices in 2011, from left to right: CEREC (Sirona Dental Systems), LAVA C.O.S. (3M ESPE), iTero (Align Technology), and E4D (E4D Technologies).

Digital diagnosis with fluoroscopy showing fractures and caries (with SoproLIFE [ACTEON North America]).

In general, do you see any further significant implementation of digital impressions (scanning) at the current price levels to get into this technology? What will it take to get this great technology integrated into a higher number of practices?
Dr. Feuerstein: As with many technologies, you would think that the costs associated with manufacturing these systems should eventually go down. Part of that scenario is based on the fact that the raw components will be cheaper and manufacturing costs will follow. In the mass markets where thousands of units are being sold, this is true. Dentistry is what is known as a small vertical market. There are a limited number of customers, and not everyone buys every item. In the United States, there are about 150,000 dentists and not all are in practice; fewer yet are practice owners—certainly less than 100,000 offices. Companies selling the digital impression systems are not selling hundreds a month (actually, they don’t divulge any of these figures, so that is my personal guess), so they are not being mass produced. Having been in a few of the manufacturing facilities, most of this production is done by hand. So, even if the component costs do drop, there could be a minor cost decrease but probably not a dramatic drop, at least with the current products and technologies.

Companies also have to recoup their initial research and development costs, which could be millions, including FDA and 510K filings (some in excess of $300,000) along with continued development, as well as keeping a support team available for all their customers; these are costs that will not really drop throughout time. There are some new intraoral scanners coming into the marketplace rumored to be less than $15,000. You should note that 3M ESPE dropped their base price for their True Definition chairside scanner to about $12,000 more than a year ago. It would seem to me that the intraoral scanning marketplace may ultimately be driven by the dental labs. They are getting tired of dealing with impression materials, pouring models, scanning them, and then going into manufacturing. When I ask dentists if they weigh out the plaster and measure the water when pouring a model, there are surely only a handful who do; this, as we know, can result in immediate dimensional discrepancies. More and more lab teams want their dentists to send them digital scans. I foresee more and more dental labs getting involved in some way to supply digital scanning systems to their clients in return for a guaranteed amount of business.

There is also an age shift in the demographics of practicing dentists. Those who have been practicing for more than 20 years are quite satisfied with physical impression materials. “I have been doing just fine for all of my years in practice,” is the most common response. The newer and younger practitioners have grown up in a digital world, trusting technologies to do pretty much everything, and certainly better than methods and materials used in “the old days.” And again, as we continue to see and hear about the specific advantages of the digital scanning and CAD/CAM restorations, this will all make more sense.

In addition to all of this, next month is the International Dental Show (IDS) in Cologne, Germany. This meeting is held every 2 years and is the largest of its kind in the world, hosting more than 125,000 attendees from 149 countries. There are more than 2,000 exhibitors from 56 countries that introduce literally hundreds of new products in 1.5 million square feet of space. Many of the products have already been launched in other countries, while some are still in final prototype stages. It is a great opportunity to get a glimpse of the future and, if 2013 was any indication, CAD/CAM and implant technology will be front and center. For me, this is the “kid in the candy store” meeting, and I’m certain that I will have plenty to report on in an upcoming issue of Dentistry Today!

Dr. Feuerstein teaching at the Yankee Dental Congress High Tech Playground.	Dentistry Today’s technology editor on the prowl, finding the latest in dental technology (seen here with Douglas Yoon, DDS, of XDR Radiology).

Dr. Feuerstein’s own treatment room technology wiring: “Do as I say, not as I do.”

Do you think CAD/CAM will eventually be replaced by printing technologies for lab fabricated restorations and prostheses, or will this develop as a side-by-side with symbiotic technology? What is your projected timeline for this evolution to occur?
Dr. Feuerstein: At this time, there are very few printed materials that are “approved for use in the oral cavity.” This is currently related to fixed restorations, as we are already using printed surgical guides and some removable appliances. I saw a demonstration of a unit that printed temporary crowns. Unfortunately, the process took at least an hour. The company representative stated that they may be able to get it down to about 40 minutes, but in my mind, the time to fabricate a temporary crown, even at 40 minutes, is a deal breaker for that application of printer technology. There are a lot of companies working hard on this in dentistry; printers from Stratasys (Objet) and 3-D systems are currently being used in quite a number of dental laboratories. So far, printed ceramic restorations do not have the strength or durability of the milled zirconia, or pressed or milled lithium disilicate restorations. I will be updating information on this topic for our readers as printing technologies continue to develop and progress.

What are the 3 top and yet-to-be-introduced technologies that you can tell our readers about (if this does not get you into any trouble, that is)?
Dr. Feuerstein: These sorts of questions really are challenging. I may give you more than 3! My initial thoughts are about further improvements in current technology. Also, despite my knowledge base in the dental field, there are new ideas coming out in different areas that we don’t even think about. An example would be the creativity that is nurtured within the 3M Corporation. They have more than 40 divisions in all sorts of industries from medical, to Scotch tape, to road paint. They have frequent meetings among all of the divisions to share each other’s products, materials, and scientif­ic/commercial advances. I was told that at one such meeting, the people who had developed a new paint for highway lines invented a new reflective material. The dental division then saw it and actually used that technology for some of the filler particles in their Filtek Supreme composite resin restorative material.

SciCan Corporation has had the successful STATIM sterilizer line for many years. Their newest G4 version (as well as their Hydrim instrument washers) incorporates a small computer in the units that are connected via network wires to the Internet. These computers monitor all of the functions of the sterilizer. If there is a faulty cycle, the sterilizer sends information to a monitoring station and the office gets a notification (via e-mail, text, or phone call) that something is wrong with the sterilizer. The user can then log into the unit remotely to figure out what happened and, in some cases, order a replacement of the faulty part immediately. There are also logs of the cycles that are stored electronically to help offices comply with state board requirements as well as assisting with the obvious safety needs of the practice. This type of technology will soon be embedded in other equipment, hopefully saving us from a lot of unnecessary worry. I recently saw an entire self-monitoring dental unit, Planmeca’s ProX, that was keeping track of hours of use of various components including bulbs, chair mo­tors, curing lights etc; this integrated technology also keeps track of services like waterline or vacuum system flushing, and more. Further advancements and applications of these sorts of technologies will hopefully reduce unexpected downtime.

Oral diagnosis has also started to become high-tech. We have gone past caries detection dye and are using devices to change the way we “watch” or find caries. Diagnodent from KaVo led the way, using a low-power laser to fluoresce carious areas and give a quantitative measurement showing the extent of the decay. Air Tech­niques’ Spectra and ACTEON North America’s Sopro­LIFE and SoproCARE use a camera and fluoro­scopy to highlight caries from the outside of the tooth as well as making sure all of the lesion has been removed during operative procedures. DEXIS has recently introduced a combination camera and transillumination handpiece that shines a bright light through the tooth and captures images that show fractures and decay. And the Canary System from Quan­tum Tech­nologies uses a novel energy conversion technology (photothermal ra­diometry [PTR] and luminescence [LUM]) to image and examine a tooth in order to help find cracks or caries around the margins of restorations including crowns, and with extrapolation even under amalgams. These are truly essential tools to be more accurate with your diagnosis. In addition, watch for new saliva diagnostics and biological markers to aid in finding and treating high-risk patients for caries, perio­dontal disease, and oral cancer.

I have also been watching a company called S-Ray (s-rayinc.com) that is working on using ultrasonic waves to be able to “see” under res­torations, through soft tissue and fluids to give precise imaging of things like caries or even perio pockets. In the future, technologies like these could be an alternative to radio­graphs, or if you push the imagination, digital im­pressions without the need for retraction or perhaps use in perio­dontal charting.

Lasers are of course changing some of our operative and periodontal procedures. Without getting brand specific, there are hard-tissue lasers that now replace the handpiece for many procedures, and due to the nature of the “cutting” technique, reduce the need for local anesthesia. There is also good evidence that, with proper wavelengths and settings, perio pockets can be reduced and bone seemingly regrown around pocketed roots and failing implants. Many of these specific products have been on these pages and more will be coming. Speaking of perio, there is a procedure called perioscopy, employing a unit that uses tiny ultrasonic tips along with fiber-optic lighting and a tiny camera that actually sees into a perio pocket and can visualize calculus (root fractures too) on the roots down to the bottom. Dr. John Kwan is showing remarkable nonsurgical results in scaling and pocket reduction when using this new technology. John has partnered with Danville Corporation to help him spread the word of this new technology.

You have a large knowledge base in the area of technology, and we are proud you have joined our team at Dentistry Today as our technology editor. For our readers, would you give us a bit of a personal background at what has made you a technology expert and perhaps how your interest in everything technological was born?
Dr. Feuerstein: Well, it was probably my life’s unique experiences that led me down this path. As a young child, I was not into sports. I guess in current terms, “geek” or “nerd” comes to mind. I spent hours at home making little plastic models of planes, boats, knights, etc. I did all of the detail work like painting, decals and, of course, there was the glue. I also had erector sets, a microscope (which was great for looking at parts of bugs) and assorted electric “kits” like ones from Mr. Wizard. Then there was my Dremel tool. To this day every dentist hears jokes from their patients about how they could fix their own teeth or dentures with a Dremel. I was quite adept using it for model making and more. If Legos were around, I would have made a model of the Taj Mahal or some such thing. I was also entrenched in music, with piano, saxophone, and bassoon lessons. In addition, I dabbled in building my own stereo amplifier from Dynaco and later on, a small computer from Altair.

Growing up in New York City during the USA versus USSR space race was probably another factor. As a science and math whiz kid, I was tracked through school at a rapid pace. As a result, I was 19 in my senior year of college at State University of New York (SUNY) at Stony Brook, which did not have a premed program; so, I chose chemistry, biochemistry, math, physics, computer programming, and of course, music courses. Rock bands provided my alter ego from the science kid. The computer course taught me several languages (BASIC, Fortran, COBOL, Assembly) and, using the latest IBM 360/60, spent hours writing programs on good old punch cards. I know what all of those little holes are, and don’t forget: “Do not spindle, fold, or mutilate.” Although my BS is in chemistry, it was actually biochemical engineering. As most of my colleagues remember, biochemistry was once known as one of the most difficult (and often hated) classes in dental school. However, for me, due to my previous educational background, it was nice to be able to catch up on some sleep in the back of the room of that class!

Computers started coming into businesses in the 1960s and early ‘70s. Companies had rooms full of flashing lights and spinning tapes, and programmers were running multicolored wires in boxes to make things work. Companies like IBM, Data General, Digital Equipment Corp, and more began making “small” computers, about the size of a washing machine, that could be put into a business and do basic accounting, billing, inventory, and more. I looked around to see if this would work in a dental office. I ran out and got a Radio Shack TRS 80 and tried to write a computer program. I taught it teeth numbers and surfaces and was able to chart; nothing with graphics at that time. Of course, there were no hard drives at that time, so the computer ran on a cassette tape and it was quite slow, as you can imagine. Around 1976, a couple of companies got into the dental business. One, called Praxis from Provo, Utah, had a system that could do all of the office accounting, and it allowed you to enter treatments. Amazingly, it also printed out the ADA insurance form. It had one of those washing machine-sized central systems with a hard disk that measured about 30 inches in diameter and had a remarkable 2 megabytes on each side of the disk; it took 2 people to do a backup with these. The CPU was a whopping 64 kilobytes on a circuit board that was hand-wired. (I still have them as souvenirs). There were also “dumb” terminals, allowing a few people to have access to this data. To get a demo, you called the company in Utah and they drove to your office with a giant truck that had the system on it and did the demos. It cost about $25,000 in 1977. A Ferrari, at that time, cost about $18,000, so I bought the computer on the easy payment plan, showing my priorities.

It wasn’t until 1981 that the first IBM PC was introduced, giving us a small affordable system, and with more dental software being written for these systems. The Apple II had been around for the previous 2 years but really had no impact on businesses. I also got my hands on an Osborne “portable” computer somewhere in that time period. As more systems came into dentistry, I found myself getting phone calls from companies asking for my opinion; you see, I could speak 2 languages: computer and dental. With time, I became instrumental in helping to develop and field test a number of new systems. At that time, my primary focus was to show up at dental meetings and to teach what a computer could do. I also did some writing for a few early dental computer magazines. One dentist who was in the forefront at that early time was Dr. Ellis Neiburger, who had one of the first tech magazines to be published. There was also the late Robert Davis, who published Tools R Us. Drs. Barry Freydberg and Claudio Lovato also earned my respect for being forward thinking in the computer world as this technology related to dentistry and we continue to be good friends. Also, as the Internet was in its infancy, Dr. David Dodell was instrumental in bringing the dental community together in the first virtual dental forum. He has continued to be a leader in dental technology education, and I am indebted to David for bringing me, and many other current luminaries, into the forefront of the dental technology community.

And, as you can see, the quest into dental technology had its interesting beginnings and it has never ended. My current challenge is to keep up with the extremely rapid advances that we are seeing in so many products and processes, and to effectively sort them out according to their actual relevance as related to enhancing our practices. As Dentistry Today’s technology editor, I will do my level best to keep everyone informed and up to date and tuned into what really matters to the clinician and team in the world of technology!

Dr. Adams: Paul, I want to close this interview by thanking you for taking the time out of your busy practice and travel schedule to share your thoughts. We look forward to the addition of your insight and expertise moving forward. I know that our Dentistry Today readers and editorial team will truly benefit from your many contributions yet to come. Welcome aboard, my friend! Now, beam us all up!

Dr. Feuerstein received his undergraduate training at the State University of New York at Stony Brook and is a 1972 graduate of University of Medicine and Dentistry of New Jersey in Newark. He maintains a general practice in North Billerica, Mass, and is an adjunct assistant professor at Tufts University School of Dental Medicine. He installed one of the first in-office computers in 1978 and has been teaching and consulting since then. He is currently the technology editor of Dentistry Today and a high-tech writer for the Journal of the Massachusetts Dental Society. He is an ADA technology lecturer, speaking at its annual sessions, and he has been speaking at the Yankee Dental Congress meeting for more than 20 years as well as at several state and local dental association meetings. He has currently been studying new CBCT, CAD/CAM, digital impressions, and treatment planning and has been incorporating these technologies in current and upcoming articles and lectures. He was named Clinician of the Year at the 2010 Yankee Dental Congress. He can be reached at drpaul@toothfairy.com.

Disclosure: Dr. Feuerstein reports no disclosures.