I’ve been in dentistry for a while now. Even though I’m not as young as I used to be, I like to tell people, “I was born right on time!” You may be asking yourself why I say that, but don’t worry, this article is going to be devoted to that answer, and I’ll also tell you where I think we’re headed.
The biggest reason I say I was born right on time is that I am a gadget guy, and there has been no greater influx of technology than the time I’ve been in practice. I’ve been lucky enough to have started an office that was 100% paper based and watched the profession make a steady digital evolution. The progress has been amazing and is not only allowing doctors to do things faster but also to do things better. For those of you who haven’t yet been practicing for a couple of decades, let me explain a bit.
When I started practicing in the 1990s, intraoral cameras and digital x-rays were not common. Both of those technologies were cart-based and didn’t connect to anything. If you wanted to take a digital x-ray, you wheeled in a cart that had a laptop and some big pieces of hardware that allowed the sensor to connect to the laptop. Once the x-ray was taken and saved, the only place you could view it was on that cart-based system. It was the same with the intraoral camera. Both systems required their own expensive hardware that was configured to only work with the system.
Moving carts around the office was cumbersome and obviously not efficient. The operatory computer changed all of that. By the late 1990s computer processing power and hard drive space became incredibly inexpensive. Suddenly it was much more affordable to put a computer in every operatory. Practice management software expanded from only accounting into digital charting. Suddenly, keeping patient data in a digital format was possible.
That also meant that the operatory computer became the centerpiece of record keeping. Charts could be opened anywhere, and clinical notes could be entered the moment that treatment was completed. The operatory computer also meant that cart-based systems disappeared as x-ray sensors and cameras connected to the operatory computer. This created a hub-and-spoke system where the same computer that held the chart also connected all the peripheral devices.
Efficiency skyrocketed. Offices quickly installed networks and had computers in every treatment area. Everything patient-related was stored in the digital chart and could be accessed with a few mouse clicks. Manufacturers created devices with a digital mindset, and connecting things was simplified. Offices quickly adapted to this new digital environment, but it took a few years for every office to move to these workflows.
Around 2010 the profession saw another influx of change. Intraoral scanners and CBCT began to make inroads into offices, and the transition from 2D to 3D dentistry began to take hold. Those two-device categories moved treatment planning and treatment into a digital realm that the founders of modern dentistry probably couldn’t have even imagined. They allowed the doctor to look at a screen and see things as they truly were. We could rotate images in any direction with no distortion. Up to that point a doctor used training in anatomy to look at a 2D x-ray and picture in their mind how the situation truly existed. Being able to actually see things as they truly were was revolutionary. It allowed us to see the patient as they actually existed. Diagnosing and treatment planning became much easier and clinical outcomes more predictable.
Virtual implant placement became a reality, allowing a doctor to “drag and drop” an implant into a CBCT scan. That virtual placement could then be used to create a surgical guide that replicated the digital placement exactly. Intraoral scans allowed doctors to magnify their preps and rotate them to see exactly what the lab tech would see.
Moving to digital impressions also allowed the growth of in-office fabrication. Mills capable of creating amazing crowns and 3D printing systems capable of creating almost anything imaginable were successful directly because the patient scans were digital and precise.
The only drawback to the move toward true 3D dentistry was in integration. Similar to the late 1990s, these new systems were standalone and didn’t interface or integrate well into the existing network architecture or workflows. We again had separate parts that were handled by themselves. The clinical outcomes were well worth the sacrifice, but efficiency needed to return.
Around 2023 dentistry saw another incredible revolution to our systems. Artificial intelligence had been making slow inroads into lots of systems, but it exploded across the industry with the release of ChatGPT. Suddenly the entire world was aware of AI and the amazing things it could do. Of course healthcare comes with serious guardrails to ensure patient safety and efficacy, so for a few years AI was mainly seen in the area of radiographic analysis of 2D images.
Now we are seeing wholesale changes to our systems and workflows. AI is great at finding common data points, and because a large number of offices are digital, AI is now finding its way into workflows through several avenues. Offices are using AI for insurance verification, handling inbound phone calls, scheduling, and billing, just to name a few applications.
However, it doesn’t stop with administrative tasks. AI has taken the clinical side of dentistry by storm as well. AI can now analyze CBCT data and intraoral scans. Systems are analyzing radiographs and converting the information into automatic clinical charting. It’s segmenting and identifying anatomic structures, facilitating airway analysis and inferior alveolar nerve tracing.
In the very near future, we will have what I like to refer to as the “continually updating 3D patient.” Imagine the following: Many offices are now taking a CBCT image and a full-mouth intraoral scan as part of their new patient intake process. In the very near future AI will be able to look at both of those files and find enough common datapoints to merge them together. That will mean the intraoral scan will actually be placed inside the CBCT. Then every time a new intraoral scan is taken, that scan will be placed inside the latest CBCT to give us an exact digital view of the patient that changes as they change. Doctors will be able to see their patient at any point in time that they have been a patient of record.
Systems currently exist that allow for motion tracking of patients’ occlusion. These systems use multiple cameras to capture the movement of the patient’s jaw as they open, close, and perform lateral excursions. That movement can then be paired with the intraoral scan to give the doctor and the lab a virtual digital articulator that shows the patient in full range of motion.
There are also current systems that do texture mapping of the patient’s face that can be merged with the intraoral scan to show the intraoral scan inside a full color 3D image of the patient’s face. This allows the doctor to perform digital smile design and then show the patient a new smile as it will appear to them when the treatment is concluded before any treatment is rendered.
The change in treatment for large or difficult cases will be profound. Imagine prepping a full-arch case with a difficult occlusal scheme. Everything can be designed digitally, and temporaries can be 3D printed in incredibly esthetic and durable resins. This allows the patient to wear the actual result for as long as necessary. Changes can be made to the temporaries to “dial everything in perfectly” before creating the final permanent restorations. Need to increase the vertical? Digitally open the bite and reprint the case to the new established vertical dimension.
This can also be used in difficult esthetic cases. Dentists know that smile makeovers can sometimes be difficult. The first step will be to show the patient the new smile on a screen where it looks exactly as it will appear when finalized. The patient can see their new smile just as it will appear in a mirror at home. The teeth are prepped and the smile design is used for 3D printed temporaries. The patient can wear the temps for as long as they’d like. Doctors can make changes to the temporaries in the mouth until the patient is 100% happy with the look and feel. When the patient is ready to move forward, the adjusted temporaries are scanned with the intraoral scanner and that scan is used by the lab to make the final result.
Stress will go down as predictability and patient satisfaction go up. Our systems are about to merge again into even more smooth digital workflows as AI allows another round of integration of the profession.
I started from a 100% analog, paper-based system that was labor intensive. I’ve seen it change throughout my career to almost 100% digital. For some things I do now, the workflow is 100% digital, where the only things that physically exists are the patient and the delivered crown or appliance. Being able to watch that process and be part of it gives me a perspective for how far the profession has come. The best part? It is only going to get better. That is why I was born right on time.
About the Author
John Flucke, DDS, maintains a private practice in Lee’s Summit, Missouri. A graduate of University of Missouri–Kansas City with degrees in psychology and dentistry, he is a past president of the Greater Kansas City Dental Society and Missouri State Peer Review Chairman. Dr. Flucke lectures widely on clinical dentistry and technology, writes a dental blog, and consults with manufacturers on developing techniques, technologies, and products.
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John Flucke, DDS
