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In the rapidly advancing world of dentistry, in which evolving technologies play a steadily increasing role, many patients have come to expect state-of-the-art technology to be a standard aspect of their care. In their personal and professional lives, these patients regularly utilize technology for the convenience and immediate results it offers, and they seek this experience in their healthcare interactions, as well. In fact, it is likely that patient experience will eventually overtake cost as the key differentiator in choosing a dental practice; it has been reported that currently 86% of dental patients are willing to pay more for an overall better experience.1 Perhaps not surprisingly, dental patients who have become accustomed to accessing goods and services remotely in their day-to-day lives are examining the extent to which a dental practice is adopting the latest technologic advances, and are looking at this as a cue to the quality of care and overall experience they can expect to receive.1
Concurrent with this change in the expectations of patients, the shift to digital workflows in dentistry has continued to increase, with both clinicians and patients choosing digital over conventional options in greater and greater numbers. It has been reported that approximately four in five patients prefer digital impressions to conventional impressions, and that 88% of dentists also prefer delivering digital impressions.1
From the perspective of both the patient and the clinician, digital dentistry has several advantages over traditional processes. This is particularly evident in the use of intraoral scanners for creating impressions. Digital impressions, more commonly known as digital scans, offer patients greater comfort, are more efficient to perform and deliver, and involve the need for fewer impression remakes than traditional impressions.1 Used for the fabrication of impressions for restorations and orthodontic aligners, digital scanning results in a simplification of clinical procedures, especially in complex cases,1 ultimately elevating both the quality of treatment and the overall patient experience.
INFECTION CONTROL THROUGH THE USE OF DIGITAL WORKFLOWS
Throughout the United States, the COVID-19 pandemic has had a substantial impact on dental practices, on multiple levels. The pandemic has driven home to dental health professionals everywhere the importance of demonstrating an increased level of attention to the needs of patients, not only by ensuring the highest infection control standards, but also by showing patients who may be anxious the empathy, care, and concern that they require from their healthcare providers.
The COVID-19 pandemic has also accelerated the implementation of digital workflows.2 Computer-aided design/computer-aided manu-
facturing (CAD/CAM) technology was first introduced in the 1970s,3 and in recent years digital dentistry has evolved to provide easier planning of treatment, case acceptance, and reduced treatment times.4 The adoption of remote, at-home services, another recent development that has been heightened by the pandemic, is expected to become a long-term trend and indeed is likely to become a permanent aspect of dental care.
By using digital technologies, which involve fewer physical "contact points," dental clinicians can create a more "touch-free" patient experience. This in turn may result in an overall safer clinical environment by decreasing the risks of cross-contamination and enhancing infection control. Working with conventional impressions carries various biohazard risks for the clinical staff of the dental office as well as for the laboratory technicians, as traditional impressions may be contaminated with saliva and blood, increasing the likelihood of oral pathogen transmission. This potential for contamination also extends to the creation of conventional restoration models, while the transport time to the dental laboratory may allow for further growth of these contaminants. Simply put, the more contact points that exist during the process of fabricating impressions and restorations, the higher the risk of contamination and infection transmission. The use of digital workflows, by contrast, provides greater biosafety and protection for clinical staff and patients alike.
DIGITAL IMPRESSIONS VS CONVENTIONAL IMPRESSIONS
Conventional impressions have a long history of success, and dental clinicians have a longstanding familiarity with the traditional processes and techniques involved in their preparation. In addition, the creation of tradi-
tional impressions is associated with lower initial costs than digital impressions and is initially simpler to perform. However, the process also takes longer to complete and is less comfortable for the patient,1 while inaccuracies in the details of the impressions-which may be compromised by holes, voids, or tears, necessitating remakes-are more common than with digital impressions.5
Intraoral scanners are devices used to capture direct optical impressions. The images captured by the sensors are processed by the scanning software to create a three-dimensional surface model, which is the digital alternative to traditional plaster models.1 Digital intraoral scanning requires higher upfront costs and involves a learning curve for the
clinician, which for some can be challenging at first. However, digital impressions are highly accurate, with studies demonstrating a significant reduction (of approximately 22%) in remakes.3,5 As mentioned earlier, digital scanning helps mitigate transmission of pathogens. Digital impressions can be also be completed with greater patient comfort and more quickly than traditional impressions1,6: once a clinician is proficient in the technology, a successful digital workflow will typically reduce the time involved in the process by 4 to 6 days.7 The time necessary for completing traditional impressions compared with digital impressions is compared in Table 1.
Because digital scans are delivered electronically in real time to the dental laboratory, laboratory shipping costs are reduced and turnaround time is shorter. Overall, intraoral scanning results in greater efficiency for the dental practice, as digital impressions result in a more efficient technique with less preparation and retake time,6 and ultimately provides a substantial return on investment for the practice. In the author's experience, the revenue typically generated by approximately seven aligner therapy cases costs is generally sufficient to offset the costs associated with the initial purchase of an intraoral scanner (Figure 1). Cost comparisons of traditional versus digital impressions are shown in Figure 2.7
CHARACTERISTICS OF HIGH-QUALITY AND POOR-QUALITY IMPRESSIONS
The ultimate success of both restorative dentistry and aligner therapy is always determined by the quality of the impressions provided to the laboratory.
With a high-quality polyvinyl siloxane (PVS) impression, occlusal surfaces should be detailed and accurate, gingival margins should be defined and clear, and the distal surfaces of the molars should be captured. In general, the material of the impression ought to be intact and free of imperfections. With a high-quality scan, the digital model should have no holes, missing gingiva, or excess material, and at least 3 to 5 mm of gum tissue should be captured, with the arches oriented in occlusion.
With poor-quality traditional impressions, bubbles, insufficient materials, and material "pulls" result in inaccuracies in the impression.7 Impressions that have these inaccuracies cannot be used for rendering accurate aligners or well-fitting restorations and will inevitably need to be remade. With a poor-quality scan, problems may include holes due to a failure of the scanner to capture sufficient tooth anatomy, as well as minimal material captured in the gingival areas. These inaccuracies are usually the result of not scanning a tooth for the proper length of time, not allowing the scanner to stitch together segments, and/or failing to rotate the scanner to the needed areas. The advantage of an intraoral scanner, however, is that the clinician can quickly add to the scan as needed, or the scan can be easily deleted and redone, if necessary.1
ACHIEVING HIGH-QUALITY INTRAORAL SCANS
The techniques for achieving high-quality digital scans can be used for the creation of restorations as well as for orthodontic aligners. Both arches should be scanned, regardless of whether only single-arch treatment is planned, as this is necessary to determine the patient's occlusion; attempting to recreate the occlusion based on one arch is prone to error. For the creation of aligners, the scan should always capture at least 3 to 5 mm of gum tissue to avoid creating a flare at the edges of the aligners that will cause discomfort for the patient. To ensure a more accurate bite registration, as much of the occlusion should be captured as the scanner will allow.
Depending on the scanner and the digital workflow, the scan may need to be converted to an STL (Standard Triangle Language) file and saved to the clinician's computer. For example, with any clear aligner submission, the scan would be submitted through a doctor's portal by selecting the scanner used and then uploading the appropriate files. If a direct upload scanner was used, the clinician could submit the scan through a doctor's portal by selecting the scanner with direct upload capabilities, complete the required scan, and submit using the relevant workflow as usual. Note that if the scan is being submitted as an STL file, it should always be inspected visually before submission.
INTRAORAL SCANNING OPTIONS
A fully integrated intraoral scanner can enable a dental practice to grow and differentiate while at the same time providing a fast "break even" on the investment. How the dental practitioner chooses which scanner to use in his or her practice has become much more complicated today, as the market has been flooded with numerous scanner options. It is beyond the scope of this article to discuss the extent of these options and technologies. However, it is important to note that in selecting a scanner, there are many factors to consider. In addition to cost considerations, the practitioner will need to assess the needs of the practice. It is necessary to determine whether the practice's needs are best served by a scanner that has an open or a closed platform, and to note what restrictions a particular scanner may have; this is especially important if the clinician wishes to use it over multiple interfaces and companies, as not all scanners allow this. Also, beyond the outlay costs, the additional costs that the practice may incur must also be considered. For example, some scanners require monthly maintenance fees, while others do not; some offer sterilizable scanner tips, whereas others charge an additional recurring cost for these tips. As with the purchase of any dental equipment, the purchase of an intraoral scanner represents a significant investment, and the clinician will need to research the various options carefully.
REMOTE PATIENT MONTIORING AND VIRTUAL CONSULTATION
The digital "ecosystem" of intraoral scanners (with the exception of closed system scanners) allows for HIPAA- and GDPR-compliant remote patient monitoring and virtual consultation. These remote services can reduce direct office time for the patient, increasing a "touch-free" experience while helping to ensure better compliance for those patients who prefer or require the convenience of remote dental monitoring. Unnecessary appointments are also avoided, by enabling patients to have appointments only when needed. In addition, remote patient monitoring and virtual consultation can be used to address emergency cases.
These remote services are implemented by means of a simplified remote monitoring platform and patient Applications. For dental monitoring, the patient's oral condition can be assessed through the use of a scan box and cheek retractor that are provided to the patient as part of the monitoring kit, while the patient uses his or her own smartphone to take the necessary scans for the assessment. These images are then transmitted to the clinician by the patient via a remote link on the clinic website; the clinician assesses them to create a report of the patient's oral condition with minimal delay and provides objective treatment options to the patient. For patients who are receiving aligner therapy, remote patient monitoring can allow tracking of aligner treatment; with aligner monitoring, the patient receives notifications to take scans at home using his or her smartphone, which are then analyzed by artificial intelligence (AI), with automated communication and instruction provided to the patient. At the same time, a report and instructions generated by AI are sent to the clinical team, who are also able to receive and send necessary messages.
By increasing the level of patient compliance, remote patient monitoring for clear aligner therapy helps reduce the number of refinements needed and elevates the overall patient experience. In addition, remote patient monitoring and virtual consultation services allow the dental practice to allot more time for new patients by reducing the number of in-office appointments per case, as well as by decreasing the amount of time needed for each case.
As patients have come to expect dental care that involves both fewer physical "contact points" and the higher quality that technology offers, they will continue to seek out dental practices that utilize digital workflows to provide them with a more efficient and seamless experience. This is a trend that has accelerated during the COVID-19 pandemic, and is anticipated to continue into the foreseeable future. In addition to meeting the expectations of patients, incorporating proven digital workflows can dramatically improve the efficiencies and overall productivity of the dental practice. When deciding to invest in intraoral scanning workflows, one should consider a system that is designed to meet the needs of the general dental practitioner, enabling fast and accurate intraoral scanning as well as providing remote monitoring and consultation services that will bolster the productivity of the practice. Clinicians who become proficient with the technology will find that using intraoral scanning to create digital impressions is more efficient than traditional processes, reducing the time needed for impression making, simplifying clinical procedures, and improving the accuracy of the impressions. Ultimately, implementing digital workflows will increase the efficiencies of the dental practice, while fulfilling the expectations and needs of patients who are accustomed to technology and look for state-of-the-art advances to be incorporated into their care.
About the Author
Michael Cohen, DDS
Lakeside Family Dental
Burlington, Ontario, Canada
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