...we are seeing a lot of new digital impression systems coming into the marketplace....from familiar...[and] new manufacturers....
The last quarter of 2019 was very busy with new product introductions as well as an interesting computer issue that will affect every office. This “issue” is Windows 10. As of January 14, prior versions of Windows are not supported. You might think that this is not a big deal; after all, how often do you call Microsoft for Windows support? That is not the big story: They will no longer update the operating system with security enhancements. As you know, there are new malware and ransomware attacks, viruses, etc, that not only make your systems unusable but also expose your data to the outside world. We all have sensitive patient information in our systems. A breach is a HIPAA violation, and the penalties are staggering. Those of you who have not looked at the upgrade to Windows 10 could be in for a big financial surprise. Most of the older computers and workstations cannot be upgraded from, for example, Windows 7 or 8. In the simplest terms, the system requirements are larger, and the processing power is more demanding. I am not saying that it is impossible to run the upgrade, but computers will not run properly if they are not configured or if certain components are not upgraded. This could mean replacing every computer in the office and then reconnecting all of your hardware (digital radiography and intraoral cameras, for example) as well as reinstalling your practice management systems. Some of you might be willing to do it yourself, but just the time involved in reconfiguring even a small office with 3 to 4 treatment rooms, a front desk, an office, a server, etc, is a daunting task. I have been asked to look at some IT company proposals, and they ran from $25,000 to $80,000 in “just a simple GP office.” Take a hard look at what you are running, and do not ignore this as the fines will make that upgrade investment look like, as they say, chump change.
Speaking of computers, I have had a chance to work with some new keyboards and mice that are totally waterproof and disinfectable. There isn’t a very good technique to wipe these down between patients. Offices tend to use things like Saran Wrap or blue sticky barriers, at least on the mice. I was given a couple of wired and wireless units to use in my office, and we did our best (as requested) to try and destroy them. We sprayed them with everything we had and submerged and scrubbed them in the sinks, and they are still working. Check out Man & Machine’s products at man-machine.com.
On another front, we are seeing a lot of new digital impression systems coming into the marketplace at initial costs of under $20,000. Some are from familiar companies, while others are from new manufacturers hailing from Denmark, France, Belgium, Korea, China, and more. As I look at each of these systems, my initial thoughts are that they all seem to scan, but you are usually only getting basic scan software or the ability to use a third-party program like Exocad. As said, they all seem to scan (at least based on a typodont that I tried at a trade show) and all are “open,” meaning that you can create a standard file, such as an STL file, that can be used by any laboratory or open software. Many of these will be sold by independent distributors, and others will be sold direct. There are users’ groups for some of these new products online that are either hosted independently or through social media sites, like Facebook. As more practitioners use these products, more peer-to-peer feedback is generated for improvements that the manufacturers and distributors see instantly, and they often implement changes quickly. The larger companies, of course, make changes based upon user feedback, but some of the smaller ones have upper management monitoring and responding directly to the users, thereby speeding up development.
Despite this “competition,” the legacy companies are constantly improving hardware and software and also have thousands of cases that have been done as well as thousands of users giving constant feedback through many channels, including large user meetings. One interesting situation in the marketplace is that Midmark has now taken over the True Definition Scanner (formerly 3M) and is working on improvements that will be introduced shortly. They have been showing the product at the past few meetings.
Finally, a few years ago, I wrote about using buffered local anesthetic with sodium bicarbonate. Many dentists have used this idea in their practices, but it is a bit cumbersome to implement. Two companies, Anutra (anutramedical.com) and Onpharma (onpharma.com), have systems that simplify the process. The latter company went through some corporate changes and was off the grid, but it is now back (and, as they say, better than ever) with the original founders running the show. Originally, it was only used with lidocaine; they have now added use with standard carpules of articaine, prilocaine, and mepivacaine. Buffering, if you are unfamiliar, shortens the time it takes for the patient to get numb, leads to a more comfortable injection, and (anecdotal) provides the patient with more profound numbness. There are clinical references and more information on both companies’ websites; they are eye openers if you are unfamiliar with the process.
This month, the Chicago Dental Society’s 155th Midwinter Meeting will take place; historically, many new products have been launched there. I have my running shoes ready for this show and will be reporting on any interesting developments at the show both here and online at dentstrytoday.com.
There are many [podcasts] out there....Some are full of technical information, some are like Ted Talks, and others are just entertaining with some good dental information thrown in.
One of the best (and sometimes worst) ways to learn about new technology and dental procedures is by scouring Internet resources. Our own website (dentistrytoday.com) has a lot of information in both text and video formats. Some content comes directly from manufacturers, while the bulk is from clinicians. During the course of a day in my practice, I sometimes sneak away before a patient is seated and look for an instructional video or information on a procedure. Many times, I am directed to YouTube, where you could probably duplicate your entire dental school education. Some examples are protocols to cement certain restorations; how to insert an overdenture attachment chairside; and indications and instructions for the use of silver diamine fluoride. (Teaser: I will have a lot of new information on this interesting product/process in the near future.) Many of these videos are put up by individual dentists, hygienists, assistants, or lab technicians as a sort of public service. Everyone wants to be an Internet star! Of course, there are great videos and some questionable ones, and all are of varying quality.
For years, people have published podcasts. There are many out there, and if you have a long commute and don’t want to hear the the day’s news, they are quite interesting. Some are full of technical information, some are like Ted Talks, and others are just entertaining with some good dental information thrown in. I will mention a few here, but a search for “dental podcasts” will direct you to lists and reviews of many. There is a lot of crossover on the Internet, as some of the groups publish on their own sites and mirror on Facebook. Do whatever is easier for you—a similar search on Facebook or Instagram will fill your bucket. There are several formats, with some being dissertations from one person and some having guest presenters, while most seem to use an interview format. Some of them are targeted toward clinical issues, some toward practice management, and some focus on wealth management, and others still are general and even social. Here are a few that I follow and invite others to try. (Note that this column, as with all sections of Dentistry Today, are easily found on dentistrytoday.com. I may update this column online with direct links to podcasts if there is interest.)
I must say that my dear old friend Dr. Howard Farran really knows how to dig deep into an interviewee in his podcast, Dentistry Uncensored with Howard Farran. I have carefully avoided Howard over the years as I want to keep my deep, dark secrets from the world.
One of the most popular podcasts is The Thriving Dentist with Gary Takacs, which looks at the business side of dental practices with great insight. The Dental Hacks Podcast, hosted by Drs. Alan Mead and Jason Lipscomb, is a no-holds-barred look at dentistry with a bit a humor and sarcasm. Dr. Tarun “T-Bone” Agarwal, one of the premier experts on digital dentistry and sleep apnea, entertains on T-Bone Speaks Dentistry. Want to make your fortune? Check out The Dentalpreneur Podcast with Dr. Mark Costes. One of the newest podcasts is Dr. Chris Phelps’ Dental Slang Podcast, in which the interviewees tell how they explain dentistry to patients and each other in our own code and give helpful clinical and management hints in the process. And don’t forget that the ADA has a couple of interesting podcasts: Tooth Talk and the non-clinical Beyond the Mouth.
There are numerous groups on Facebook, a few being offshoots of these podcasts. One example is Dental Hacks Nation! Most are private groups that require registration, but you really don’t know who is looking at the posts. A lot of the text, photos, and videos are quite graphic. (Facebook has a filter that obscures potentially graphic content; click the warning message to diplay the post.) Since many of these forums are international, you get to see interesting cases and techniques that you never really thought about. And as you remember from some of the wild pathology cases and photos you saw in dental school, some of these actually appear in people’s offices and clinics around the world. A few of these forums are designed to show failures, which are always eye-openers. However, I am always afraid that some may be from clever Photoshop users who have nothing better to do than to start trouble, but the majority are honest. A fun one is an implant-failure group with a name I cannot print here, but just search “implant club” on Facebook to find it. A wonderful group is Dental Clinical Pearls, which is moderated—an important factor in keeping it top-of-the-line. The cases and discussions are high-end, and many of the members post techniques with detailed information and excellent photos. Also check out the new group led by Dr. Sandy Pardue, Dental Gumbo, which includes practice management discussions and tips.
The problem is that some forums create their own “experts.” As I said, everyone wants to be a star, so there are some people who post very often and appear to be the latest key opinion leaders. People are followed based on the fact that they have over 1,000 posts. Some are genuine teachers, while others are merely showing off their knowledge base—you have to filter this. Still, it is interesting to see a variety of approaches to dental issues. On the other end, there are dentists like Dr. Bill Strupp, who continue to amaze everyone with superb gold restorations. In one recent post, Bill showed a buccal pit gold inlay that had been in place for 40 years. Of course, I have a few patients with buccal pit amalgams that have been in at least that long, but they aren’t as shiny!
Generally, I find that although many of the interviews or talks are from names you know, a lot are just everyday practitioners talking about their experiences, successes, and failures. There are a lot of you out in the trenches who have no desire to rack up thousands of air miles traveling to lecture but have a lot to tell us. Also, many of the posts are from dentists who have run into difficult clinical and diagnostic situations and are looking to colleagues for help. The speed at which an answer can be obtained is often surprising: sometimes while a patient is still in the chair. Private practice can be a lonely place, and it is great to realize that we are all trying to get to a common patient care goal and that there is a virtual camaraderie out there.
The bottom line is, if you are considering a 3-D printer, know what you can actually make efficiently in your office and how much you will actually use it.
Last month, the annual meetings of the ADA and the FDI (World Dental Federation) were combined and held in San Francisco as the ADA FDI World Dental Congress 2019. For those not familiar, FDI represents more than a million dentists worldwide. As usual, many new products debuted in a large array of manufacturer displays. There were also 5 days full of continuing education with top presenters speaking on topics ranging from restorative dentistry to technology to wellness. It is a bit sad that many of you missed this opportunity. Although the ADA reported more than 30,000 attendees, there were only about 11,000 dentists and 4,000 assistants. Perhaps it was due to the fact that this was the week following Labor Day; I was told by many dentists that their families had commitments (eg, the first week of school), which might have been a deterrent.
Of course, my focus was on the new technology. All of the digital impression scanners presented improvements in functionality as well as new software. A few newcomers also graced the meeting. One of the new product introductions came from Carestream Dental, which launched its new CS 3700 scanner. Its increased speed, unique shade matching, and new intuitive software created a buzz.
I describe this space as an ongoing Kentucky Derby in dentistry. As I watch the products, changes come almost monthly, and honestly, as soon as one manufacturer introduces a new feature, the others follow rapidly. At this time, all the intraoral scanners create files for dental restorations and procedures. The elder statesmen (Dentsply Sirona, Planmeca, 3Shape, Align Technology, and Carestream Dental) have proven their accuracy with thousands of restorations as well as clinical studies. One of the most important aspects of this technology is the ability to create an accurate full-arch scan with precise cross-arch measurements from second molar to second molar. One of my early simple tests for this aspect was to create a full-arch scan and send it digitally to a laboratory and have them create a hard nightguard; then I would see if it “drops in” with no real pressure points. Although not scientific, it is an inexpensive test to perform before investing thousands of dollars. There are, of course, many new companies with units from all over the world being introduced at, in some cases, significant price differences. When I spend time at a show booth looking at the new products, creating a scan on a model often looks impressive. I cannot make a judgment at that time, though, as I really need to see legitimate studies and, if possible, create some restorations in my own practice. In earlier times, I rotated various systems on loan through my office and took a digital and a PVS impression to get a clinical sense of accuracy there—not in a sophisticated lab—just as any GP would do. I sometimes had the luxury of 2 scanners and could scan a crown prep twice and compare results. Margins, contacts, and centric occlusion were easy to check with explorers, floss, and articulating paper, and I continue to do this with newer products to report back to my readers and course attendees. The advice at this time is to at least get a demo in your office and do a case or 2. Look at the ease of use and the actual handling of the wand; examine the software; and, even at this early level, get a sense of the customer support. Also, find a laboratory that will do a totally digital workflow for you. Currently, the easiest product to receive is a full-contour zirconia crown with a model, for your testing. There is usually an additional charge for the model, but keep in mind, this is part of your investment in the ultimate end results for your patients. One of the first things that threw me in my earlier days was receiving a case from a lab with a little box that contained a crown and no model; I had to raise my right hand and say, “I believe.”
One of the other areas at the meeting that added to digital restoration confusion was focused on 3-D printers. There was an array of units ranging in cost from $3,500 to $20,000. There is a lot of talk by manufacturers on the methods used to print a product. SLA, DLP, DLS, etc, caused a lot of head scratching. To simplify, the questions should be how fast, how accurate, how many pieces at a time, and how large can they be and what materials are available. The latter will help determine what you will actually do with the printer. More important is the fact that you cannot just buy a printer and “attach” it to your scanner. There is software that is necessary to design the appliance, and you must consider who in the office will do this and how much time will it take. Then there is “post-processing.” The printer doesn’t just pop out a finished product; there are sprue-like pieces that have to be cut/grinded off. The printed piece has to go through one or 2 washes. Then many materials must be cured by light, and sometimes by heat in an oven. Finally, someone must polish it for delivery. A couple of companies, Micron Dental (microndental.com) for example, do not just sell you the printer: They also have all of the finishing components and are quite honest about all the steps needed and how much time and manpower is involved. One company, Structo (structo3d.com), showed the Velox, which has a little carousel inside the unit and automates all of the steps of printing, washing, and curing (but you still have to cut the sprues and polish). Those of you using guided surgery for implants will be able to print your own surgical guides, but make sure you understand the entire process—it is not a one-click solution (yet). There was a lot of talk about being able to print dentures right in your office at a cost of, perhaps, $25. Again, this requires designing, printing, and finishing, which takes time and manpower. And there are still limitations on what materials are FDA approved for long-term use in the mouth. The bottom line is, if you are considering a 3-D printer, know what you can actually make efficiently in your office and how much you will actually use it.
Of course, the understated point here is “Do your homework.” Take some courses either at workshops or online. The resources are out there for you to make an intelligent purchase decision.
How many times have we heard the phrase “I want to improve my smile”? In many situations, the patients’ idea of what they want might be totally different from our natural response. Sometimes it’s as simple as wanting a whiter smile. The definition of “white teeth” to many patients is also far different from ours. Some of these patients are still bleaching their veneers in hopes they could be a little whiter. Other patients are concerned with “crooked teeth” that are “getting worse.” Their definition of crowding is often quite different from ours. Luckily, with the proliferation of aligner products and processes, we can often accommodate these patients with a simple, limited case. And, with a little bleaching in the final retainer, they fall in love with us.
If an office has no system or an old, outdated one, a cloud system...would allow an office to get started without a server or a complex computer installation....
Dentists who are nearing retirement are trying to decide on the future of their practices and perhaps sell the results of their years of hard work. Some have the good fortune of having children who have gone to dental school and will (hopefully) join and take over the practice. Others will look at options being presented by some of the DSOs. Some, of course, will be looking at new graduates or recent grads who are working and looking for future opportunities. These prospective buyers are often offered an associateship with an option to purchase the practice or, in some cases, purchase the office and have the seller stay for a predetermined number of months to introduce the new owner before he or she sails off. A savvy buyer enlists an agent who has experience in practice transitions to analyze the practice and try to establish a fair value, which opens up a discussion on the attractiveness of the office.
The question often asked by some older practitioners is: “Since I am about to sell, why would I invest thousands of dollars in new technology?” There are some simple answers, and they depend on the scenario. If a corporate entity is looking at the practice, they may want to put in their own systems to be uniform with their other practices. In that case, the selling doctor only needs to get the appraisal and sell the practice as is. The seller gets paid and walks away, but keep in mind that the value you think the practice has might not match up with a corporate analysis.
Another common situation is an outright sale to the new dentist, which presents a few issues. The new dentist (as well as new young staff) has been trained using a number of digital systems. First and foremost, they are used to having computers, or at least workstations, in each treatment room. This infrastructure is a part of digital radiography; intraoral and extraoral photos; and the practice management system, especially for clinical notes and the appointment scheduler. If the seller does not have these in place, the office will not only be less attractive, but, if a sale is being negotiated, the price will be lower than expected. The new dentist will surely want to get these things in place as soon as possible and will have to figure in those costs. According to a couple of practice brokers I’ve spoken with, the new dentist would prefer to have a “turnkey” situation so he or she could start producing immediately. One of the simple new product categories around is cloud-based practice management systems. If an office has no system or an old, outdated one, a cloud system (such as Curve Dental, Dentrix Ascend [Henry Schein Practice Solutions], or Fuse [Patterson Dental]) would allow an office to get started without a server or a complex computer installation: Any workstation or computer—or even a laptop, as long as it has decent graphics—can get an office up and running quickly. In addition, there isn’t a large initial outlay for software; instead, there are nominal setup fees and a monthly fee, which includes updates and even backups. Also, the digital charts (EHR) are right there.
With this infrastructure in a smaller office, digital radiography can be installed with as little as one sensor. In a solo office with 2 hygienists, one is certainly workable. This can be installed for well under $15,000, and, in some cases, this amount buys 2. Some sensors actually cost less than $5,000, and one new company, Jazz Imaging, allows the office to lease sensors for a very low initial cost and small monthly payments. However, if time is of the essence in a sale, it might not make sense to put in new technology—as long as the seller understands the dollar loss. A new owner might almost resent the fact that the office has sensor A or practice management system B when he or she had other ideas. The problem here is that the buyer could factor in removing and reinstalling different products, or even walk away.
Looking at the scenario where an associate is brought in with the option to buy, a slightly different approach could be taken. The seller could explain that he or she was about to add new technologies but wanted the new potential owner to have input. This shows a commitment to the improvements, and the new associate can actually see the costs involved and take these into account when negotiating a sale. In one practice transition I was watching, the owner purchased a cone beam scanner and took a long-term lease. The young, potentially new owner would probably not have qualified for this investment with the large dental school debt he or she was holding and now merely assumes a monthly payment on the device. The added bonus was the new excitement it brought to this practice owner in his final years of practice.
There are, of course, a number of non-technological upgrades that could enhance the practice’s value, such as having very clean floors and carpeting or adding a fresh coat of paint on the walls/ceiling.
In writing this piece, I spoke with Craig Hornung, DMD, a recent graduate of Tufts University. He agreed that, in school, he had never filled out a paper chart or used a developer and fixer, but he said there was a different vibe from many of his classmates. He and his peers are not really looking to be practice owners and take on all of ownership’s associated headaches. He also had never heard of the TV show Marcus Welby, M.D., and, once it was explained to him, he didn’t really see that concept as relevant today. This was, of course, partly related to the extraordinary debt today’s students are graduating with, and he also said, with a smirk, “We are millennials and think differently.” I guess I will have to talk with Dr. David Rice, founder of the nation’s largest student and new dentist community, igniteDDS.com, and perhaps update this whole column.
...several dental units...are physically guided by systems similar to a GPS. Many of these are used in teaching institutions but...could evolve into smaller chairside units.
In Stanley Kubrick’s film 2001: A Space Odyssey, the HAL 9000 said, “Let me put it this way, Mr. Amor. The 9000 series is the most reliable computer ever made. No 9000 computer has ever made a mistake or distorted information. We are all, by any practical definition of the words, foolproof and incapable of error.” This quote still stands as a mantra for every dental office that has ever experienced a computer malfunction. We have come to depend on these piles of wires to run our everyday practices. We are also now inundated with Alexa, Google Home, Siri, Bixby, and more, and using artificial intelligence (AI) makes us a bit lazier (“What is an encyclopedia?”) and dependent. Now, not only can we get random information, but these algorithms also seem to track and learn about us.
I must digress here for just a second and dispel a common myth about HAL. According to a few Internet sources, Kubrick’s 2001: A Space Odyssey was developed concurrently with the novel of the same name by Kubrick’s co-screenwriter, author Arthur C. Clarke, who states: “As is clearly stated in the novel (Chapter 16), HAL stands for Heuristically programmed ALgorithmic computer. However, about once a week some character spots the fact that HAL is one letter ahead of IBM, and promptly assumes that Stanley and I were taking a crack at the estimable institution….As it happened, IBM had given us a good deal of help, so we were quite embarrassed by this, and would have changed the name had we spotted the coincidence.”
So how does this relate to our practices? There are a few enterprising companies that are taking a hard look at how we practice dentistry. The first simple example comes from my friends at Simplifeye: Ryan Hungate DDS, MS, and his brother Zach. This is a company I have reviewed here before in regard to its clever integration of the Apple Watch with the Dentrix scheduler. They are working on a number of new ideas, one of which uses Amazon Echo’s Alexa. Their new product, DEXvoice, allows the practitioner to ask Alexa to bring up the last set of bite-wings; issue commands, such as “Let me see all of the images related to tooth No. 14;” and more. Find more information on DEXvoice at amazon.com and other products at simplifeye.co (not “.com”).
Speaking of radiographs, AI is making waves in our interpretation of the images. For years, Carestream Dental has had a product called Logicon Caries Detector Software. Using an algorithm that was actually developed for a project at NASA, the software actually “reads” bite-wings and predicts interproximal decay. The company claims that it shows 20% more areas of concern than seen by the naked eye. As we know, interpretation is sometimes a decision based on the doctor’s experience and also on the patient’s history. Still, it is like getting a second opinion. Logicon is only available with Carestream/RVG sensors.
Right now, Angam Parashar and Ankit Singh, co-founders of Dentistry.AI, a sophisticated artificial intelligence start-up company, are trying to take this to a higher level. They are working with a number of practitioners and clinical radiographs and studying the process of evaluation radiographs. Above and beyond looking for interproximal caries, this software is looking at recurrent caries under restorations, root caries, and more, giving the doctor areas of suspicion that might have been overlooked. It is still in its early testing, but you can get a glimpse of this project at dentistry.ai.
One company that’s using AI to identify trends and increase revenue is Patient Prism. Amol Nirgudkar and his team patented a program that analyzes your phone conversations with new patients and reports the services the caller wanted, his or her insurance information, and whether the call ended in a booked appointment. Within an hour of every new patient call that doesn’t convert, Patient Prism provides coaching tips so that your team can call the potential patient back, address his or her concerns, and win him or her back. Wow. You can get more information at patientprism.com.
Of course, we are all aware of robotic surgery, most of which is guided by a human, but now some decisions are being made by the software. There are several dental units that are physically guided by systems similar to a GPS. Many of these are used in teaching institutions but, other than the current size and cost, could evolve into smaller chairside units. For an interesting look at this technology, check out the DentSim System at dentsimlab.com. Not only does this system guide the students’ preparations, it critiques them.
There is another new robotic system out called YOMI, which was just brought to my attention by Dr. Ed Zuckerberg (who is a wealth of information). Although not exactly AI, its use of haptic robotic technology and multisensory feedback helps to achieve the right location, angulation and depth to place an implant exactly according to plan. Details are available at neocis.com.
There are other programs and devices in the marketplace, but don’t worry yet about losing your job to Wall-E.