Moving Your Practice Into the Digital Age

Dentistry Today


Transforming a conventional dental workplace into a digital dental practice represents a cultural shift from pencils, papers, and processing chemicals to modern technology. In this interview, David L. Guichet, DDS, who practices in Orange, Calif, and is a researcher and faculty member in the department of prosthodontics at the UCLA School of Dentistry, stresses that this is not an easy change for most dentists and staff.
You must first get your employees on board with the concept and then properly train them so that you can avoid frustration from the beginning. In addition, you have to install an adequate and secure network infrastructure. This includes hard drive backups, an uninterrupted power source, and a stable, hardwired network based upon a high-speed gigabyte switch. All of this requires an investment in some expert advice. Those experts may charge between $70 and $135 per hour to set up the security and backbone of your digital office, but once it is built you can usually go as many as 3 years per server with only periodic updates.
Once your digital infrastructure is in place, you are in a position to incorporate the clinical software application that best fits your practiceís needs. The effective use of clinical software can take a practice into the digital fast-lane of efficiency and patient satisfaction. Initially it will take work on your part, but soon you will experience the real benefits of a digital practice and the many efficiencies that it creates. Dr. Guichet sat down with Dentistry Today to explain how you can make the transition happen in your dental office.

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DT: How would you advise a practice to begin the process of digital transformation?

Dr. Guichet: First, the doctor should identify a software application that would provide a unique benefit to the practice. I call this the critical “Start up” application. For most offices, the first clinical application will reside on a laptop that is carried from room to room. Typically this application is kept separate from the practice management database and is backed up irregularly. This approach is cost-effective but inefficient and risky. The data stored could be lost in the event of a hard drive failure. In time, a second or a third application may be identified, which will serve as an incentive to build out the clinical hardware network to boost efficiency and security. Once the back office network is built, new applications can be added very effectively.
For us, the first application identified was the Florida Probe System periodontal charting software (Florida Probe). Shortly thereafter, we added digital radiography and digital photography on the VixWin (Gendex) imaging platform. This served as the incentive to build out our clinical hardware structure and quickly led to the removal of radiographic processing chemicals from our practice. Today most practice management software packages have partnered with digital radiographic imaging companies to create a linked radiographic-photographic imaging suite. I believe that a linked practice management-digital radiographic-photographic suite offers a practice the most stable and serviceable platform.

DT: What is required for the shift from traditional films to digital photography and radiographs?

Dr. Guichet: All in all, this shift from chemicals and film requires the ability to culturally embrace the new technology and integrate it into your practice. For some, this may seem to be impossible. Regardless of your personal bias regarding the diagnostic quality of digital radiography versus film, for patients and staff there are irrefutable benefits to digital radiography. These include a reduction in processing time and radiation exposure, as well as quick and easy access to critical patient information from any computer. One must refrain from comparing dental radiographs on film against digital radiographs printed on photo paper. The printed digital images are actually second generation and are degraded when viewed on paper. The digital images are native on a computer and are best viewed on a monitor. While viewing on a monitor subtle adjustments can be made to image contrast and brightness, and magnification can be used.
One advantage of starting with digital radiography is that the imaging software can serve as a foundation for the photographic images as well, at a very low additional cost. Doctors make a mistake in performing all digital photography themselves. I delegate nearly 95% of all the digital photography done in my practice. Every clinical staff member is trained to take a standardized, 10-view photographic series, with printed, standardized camera settings for magnification, distance, and exposure. I would warn doctors against going straight to digital photography without having radiography because youíll have an image storage and filing nightmare. With a practice management-radiographic imaging partnership-package infrastructure, you can automatically download compressed image files, which are time-and date-stamped images to the patientís radiographic record.

DT: How does one choose the right software?

Dr. Guichet: One of the most important things is to pick practice-management software that is paired with good digital radiography software. The integration of the business management package with the radiography package creates an imaging foundation. That means any photographs are included in the patient’s radiographic record and tagged to the patientís digital record. This is critical! EagleSoft has a partnership with Kodak, Easy Dental has a partnership with Schick, and the software that we use, Dentrix, has a partnership with Dexis. So, depending on your favorite practice management package, you might get the best support if you choose an established-partner brand. The benefit is that you will have a supported and proven system. If any complications occur, then training and technical support is better with partnered companies.
Once your digital records process is in place, one of the most helpful applications is the remote access to your patient information. Via communication over the Internet, one can access the schedule and patient clinical data in order to review the day. You can link into the software from anywhere. While your schedule may already be computerized, the digital infrastructure with remote access software allows you to access and review digital records and scan x-rays.

DT: How do you handle patients in your digitally based practice?

Figure 1. Patients have their intraoral and extraoral photos, radiographs, and implant tomographs performed by RDAs. Figure 2. Screen from a Florida Probe System patient education movie.
Figure 3. Digital technology facilitates a truly interactive patient experience. Figure 4. Dexis screenshot of a Gendex digital panoramic radiograph using Dexpan Digital Import (Dexis).

Dr. Guichet: Before I ever see a patient in the office, my staff has given the patient a tour of the practice. The staff has received authorization to take the patient’s digital panoramic radiograph (Figure 1), and the staff has taken the 10 extraoral and intraoral photographs according to our protocol. Additionally, while uploading the images, the patient watches a 6-minute Florida Probe System periodontal educational video (Figure 2). Then, the patient photographs and radiographs are pulled up onto the LCD monitor (Figures 3 and 4). The patient sees the photographs on the monitor while the dental assistant discusses her chief concerns with the patient. Then the assistant huddles with me. She provides a brief description of the patient’s chief concern and history. As I walk into the room, I am introduced to the patient while the dental assistant repeats everything from the huddle again, this time in front of the patient. During this, I am reviewing the photographs and radiographs. The patient quickly realizes that Iíve heard and seen the reason why the patient has come in (Figure 3). Within moments I have been introduced to an enormous amount of high-quality digital information about that patient, all with a minimum of time spent on my behalf. Almost instantly, we have formed the basis for making a more in-depth and focused decision on behalf of our patient.
This starts the visit on the basis of mutual understanding. Typically a patient enters a practice and relates his or her history to the staff and doctor. A patient can unintentionally mislead you if you donít have accurate radiographs and photographs to reference. Historically, it is at the end of the first visit, when you are really into the exam, when you find out what is actually going on. Traditionally, the dental assistant doesnít experience the exam because only the doctor actually sees inside the mouth. Then the treatment coordinator (or office manager) would need to be informed about the patient without the advantage of intraoral photography and the radiography. The old way was very inefficient.

DT: Have you noticed an improvement in efficiency?

Figure 5. Proposed implant treatment plan utilizing Deximplant Implant Panning Software (Dexis). Figure 6. A cone beam scan and an implant treatment plan using Astra Tech Facilitate Software (Materialise).
Figure 7. The 3-D virtual plan from the Astra Tech Facilitate software can be uplinked via the Internet to Materialise for the production of a computer generated SurgiGuide. Figure 8. Florida Probe System software, mandibular arch view.
Figure 9. Dentrix patient prescriptions menu.

Dr. Guichet: By having radiographic and photographic information immediately there’s tremendous efficiency. The technology allows us to communicate with the patient while the dental assistant gains an understanding of the patient’s chief concern and clinical condition. When the exam is completed, the patient sees the doctor reviewing the radiographs and photographs and making notes about a treatment plan with the dental assistant and treatment coordinator present. A picture is worth a thousand words. During a preliminary treatment plan, I will often launch 3-D software to demonstrate to the patient the quality of the 2-D (Figure 5) versus 3-D (Figures 6 and 7) digital information. We will quickly pull up photographs of other patients treated with similar needs. After I explain the treatment plan, the patient is transitioned to the treatment coordinator. The treatment coordinator can explain the advantages of complete diagnosis and why full-mouth radiographs (FMX) are necessary. Also, the coordinator is prepared to discuss treatment plans in the future. That’s just one of the ways a doctor can be very efficient simply with the use of a few limited technologies: digital radiography and digital photography.
During the patient’s second visit we complete the complex exam. The RDA?(registered dental assistant) launches the Dexis radiographic and photographic software and takes the FMX. I enter and review the patientís radiographs using the Dexis alerts to annotate areas of concern on the radiographs. Then I launch the Florida Probe System periodontal exam software (Figure 8). While the periodontal exam is being performed, the Florida Probe software gives audible warnings that inform the patient. After this, we do the restorative charting while referring back the FMX. I correlate what is seen in the radiographs with what weíve discovered clinically in the periodontal probings and the functional exams. From this information, I form a diagnosis for the patientís condition and develop an appropriate treatment plan that directly addresses the patientís concerns (Figure 9).

DT: How do you handle patient education, treatment planning, and case presentation?

Figure 10. Digital photo imported into Dexis that is used to verify aesthetic goals.

Dr. Guichet: Once the information is gathered, the patient and I discuss treatment options in a consultation room while referencing the exam findings in Dexis and the Florida Probe System on a large, flat-screen display. Our treatment coordinator is also present as I review the exam findings, proposed treatment plan, and proposed treatment sequence.
Our treatment coordinator also pulls up radiographs and photographs of completed cases from our practice. Most dentists may not have a library of completed cases, but they can use patient educational software packages from Consult-PRO, CAESY, or Guru for this. Guru is linked to the patient’s chart. If the patient has a question, you can launch Guru and pull up the vignette on the desired topic. You can scroll ahead a few seconds to the spot you want and then circle the image on the screen with your digital pen. The moment you mark the image, it becomes stored. When you close the file, it becomes linked as part of the Guru record to that patient. You now have a digitally sealed, time-stamped image of the video vignette along with the notes from that day. It serves as a very powerful documentation of informed consent. If the treatment plan is limited, your treatment coordinator has the digital records and can go into Dentrix to build and print the plan right in front of the patient.
If the treatment plan involves a number of implants, using the Gendex digital panoramic radiograph system we import that image into the Dexis software using Dexpan and use the add-on called DEX-implant (Figure 5). This add-on has a digital library of major manufacturers’ implants so you have all the sizes and shapes. The radiograph is calibrated according to the magnification factor for the given image. The Panorex CMT (Imaging Sciences International) is 30% vertical magnification for panoramics and a 44% magnification for implant tomograms, according to the manufacturer. Since panoramics are distorted horizontally but magnified vertically by a standard fixed amount, we can then use them as a guideline for treatment possibilities. We choose implants from the library and set them into the panoramic radiograph. This can serve as a reminder of the intended plan and also as a record of the conversation. This allows the doctor and the patient to visualize the position of the mandibular nerve, the sinuses, the available bone, and the various sizes and shapes of implants that are most appropriate for the given situation. With that package, the implants are drawn perfectly, exactly to scale, and have a 2-mm dash line so the patient knows we wonít get closer to a tooth or nerve than this safety zone (Figure 10). A patient sees this and usually begins to understand very quickly.

DT: Have clinical results improved with digital technology?

Figure 11. A Dexis screenshot of the patientís computer-generated surgical guide SurgiGuide (Materialise) with Astra Tech implants in place. Panoramic radiograph and the completed mandibular arch 2 weeks postoperatively.

Dr. Guichet: Certain advantages are undeniable with 3-D technology. Rather than using our eyes to see the bone, we can make many clinical decisions using the virtual access of digital radiography and cone beam technology to see bone. We can make treatment decisions about the position, depth, inclination, and orientation that a highly skilled surgeon may be able to do only after a lot of training. The younger surgeon may be able to accomplish that same positioning, but do so with a minimum elevation of flaps.
Minimally invasive surgery is more often possible with the use of the diagnostic information you gain from this 3-D planning. You can select your implant length, size, shape, and diameter, all with exquisite accuracy. In the execution, you can order guides that will assist you in getting exactly what you planned. You still have to do good surgery. If the patient requires alveolectomy or ostectomy, you can still use the older technique of large-flap surgery, but in many instances if you use minimal invasive flap surgery, there is less postoperative pain and the patient has a very good experience.

In the past, when we received 3-D CAT scans, they would be printed out on paper. The posterior mandible would sometimes slope up 15°. If you measured from the crestal ridge down to the mandibular nerve, it might look like you have 15 mm or so of bone. However, in 3-D, if you are placing the implant perpendicular to the ridge, and the ridge is on a 15° slope, the implant also has to be sloped 15°. You might find that the geometry is incorrect. Using the triangulation, you discover that in-stead of having 15 mm, you might truly only have 14 mm. You could still make mistakes interpreting a 3-D CAT scan, but you can’t rotate that CAT scan in a 2-D printout in order to see the detail.
Also, you can’t lighten or darken your printout, but you can lighten or darken the monitor image. The resolution of a digital image is quite high and very detailed. These electronic files can also be easily shared between the restorative and surgical teams (Figure 11).

DT: Do you have any final thoughts that you would like to share with our readers?

Dr. Guichet: This is not the future, it’s now! Your patients expect your office to function with the latest technology. They want access to online information about your practice and to be able to download patient forms, such as those for their health history. They want to be able to view their digital photos and radiographs to gain a better understanding of their treatment options. All of this is possible with today’s technological advances in clinical software.

Dr. Guichet is a Diplomate of the American Board of Prosthodontics and a graduate of the maxillofacial prosthetics and implant dentistry residency at UCLA School of Dentistry. He completed a graduate prosthodontics residency at the Veterans Administration Hospital West Los Angeles, a general practice residency at the Veterans Administration Hospital Long Beach, and received his DDS from UCLA School of Dentistry. He is a Fellow of the American College of Prosthodontists, a member of the Academy of Osseointegration, and a member of the Pacific Coast Society for Prosthodontists. Dr. Guichet maintains a private practice limited to prosthodontics, implant dentistry, and aesthetic rehabilitative dentistry in Orange, Calif. He is currently conducting research and is a faculty member in the Department of Prosthodontics at UCLA School of Dentistry and frequently lectures on the subject of implant dentistry and aesthetic rehabilitative dentistry. He can be reached at