Connected

“The way we communicate and acquire products has changed dramatically over the past few decades,” says Larry Emmott, DDS, professional speaker, author, and President of Emmott on Technology LLC. However, that same transparency with which he communicates, shops, and shares images in his personal life does not necessarily carry over to his professional life. “I would like the same convenient and cost-effective shopping experience that I have when I employ the power of the Internet to buy an airline ticket or shop on Amazon, and I would like to extend that ease of communication and transaction to our industry, from sharing 3D images with specialist colleagues to ordering a product or service from a dental laboratory,” Emmott says. In an ideal world, he says he should be able to access a digital patient chart, insert the digital impression and digital images, and then send and integrate that information electronically with the laboratory’s software. The laboratory’s software would accept the case and offer a menu of products and services from which he could choose the restorative product he needs, and offer an electronic prescription form for him to fill out.

Unfortunately, the same open transfer of data that is experienced when a digital picture is taken and then shared via text, social media, or email does not yet exist in dentistry. “We still have barriers to that process,” says Emmott. “Proprietary software from various vendors won’t allow communicating with the software from other vendors. So unless the dentist and laboratory have compatible software programs, we can’t communicate on that seamless level.”

It’s a frustration recognized and shared by Mike Dominguez, CDT, owner of Kymata Dental Arts in Seattle, Washington. Dominguez uses a wide variety of disparate tools available via the Internet to communicate on cases with his clients, educate his technicians, and manage his business, but most are not dental specific and must be accessed separately. These tools also do not integrate into his business management software. “Dentistry needs an open-sourced platform that is all-encompassing for facilitating communication among dental professionals and one that gives the dental laboratory the digital information it needs to manufacture products,” Dominguez says.

Chris Brown, BSEE, manager of Aclivi, LLC, a CAD/CAM technology consulting company, agrees. If a platform were developed that would seamlessly integrate patient digital data from the practice and integrate that information automatically into the laboratory’s business software, it would be a leap forward in efficiency, accuracy, and cost savings. “Currently the analog workflow requires receipt of the physical or digital impression with the prescription. To get that information into the laboratory’s business and case management software, it requires that a person at the laboratory manually enter that information, which is not only a labor cost factor but also increases the potential for human error,” Brown says. Even if the case information were submitted digitally, there is no way for that data to automatically populate most business management software programs and be in a file format that seamlessly fits into the laboratory’s digital workflow.

It’s a problem that Mike Selberis, CIO, was hired by Glidewell Laboratories to solve. “When I first came on board and looked at what all the different vendors were doing, it became clear that what dentistry needed was a standard language and platform that would allow digital information from the practice, regardless which vendor’s equipment was used, to be transmitted to the laboratory in a form that was usable and could be plugged automatically into the digital workflow.”

However, developing a standard language for open systems to easily talk to each other in a healthcare setting must also overcome the challenge of adhering to tightening data privacy standards. “We have the technology and the tools, but the bigger challenge will be building software platforms that are compliant with HIPAA and other regulatory standards,” says Dan McMaster, Global Business Director at 3M Oral Care. As a provider of critical procedure classification and communication software to some of the largest hospital systems in the country, McMaster says 3M recognizes the importance of supporting and actively participating in the standard-setting process.

“While the 3M True Definition Scanner has received much public attention for impacting digital dentistry, we are actually spending more of our time, resources, and energy on the 3M Connection Center—the cloud-based software platform enabling secure and open communication between the dentist and other third parties,” McMaster says.

If effortless exchange and integration of digital information and data is the next logical step in the evolution of digital dentistry, it is only the beginning of what is possible.

“Digital dentistry to this point has focused on automating existing procedures,” says John Kois, DMD, MSD, owner and founder of the Kois Center. “The exciting opportunity for us going forward is to utilize this new technology as intelligent systems to predict, plan, and communicate.”

Whether the issue is transmitting and communicating digital data on an open exchange dental platform or creating a digital system that helps dentists document and monitor the oral condition over time and better communicate any changes with their patients, the next-generation communication platforms will begin to tie together disparate technologies into a rich networked fabric that allows effortless usability among the players and offers the ability to tap into embedded artificial intelligence that can use the captured data to enhance digital workflow or act as a tool for assessing patient risk factors for treatment plan considerations.

It was the former issue that Selberis hoped to solve when he joined Glidewell. The initial problem involved automating the process for receipt of digital impression scan data from a variety of different scan technologies as well as creating a digital prescription that would then populate and integrate with the laboratory case management software. He found that all the impression scan companies, even those with open-architecture platforms, had their own unique way to communicate effectively from their system to another vendor’s system; some were proprietary and required a purchase of a special license and a means to convert files to STL format to perform the work within their system. Selberis contacted Andy Stark, General Manager of Jenmar International, to ask if he was willing to work on creating an industry-standard file format through which information from the practice could be transmitted to the laboratory using a common language. “We established a not-for-profit organization called OXDIG (oxdig.org), which stands for Open Exchange Dental Interoperability Group, and began seeking out other companies that might be interested in participating and providing input,” Selberis says. “We set about creating a standard language, which we called UDX or Universal Dental Exchange, that could convey data in such a way that if one system exported a digital file, another could import it and would know what to do with all the meta data contained in the file.”

When Selberis joined the ADA Standards Committee on Dental Products and found that the group had been searching for a CAD/CAM universal file standard, OXDIG and UDX were submitted to the committee for review and consideration. The committee, which functions as the US representative for the International Organization for Standardization, then created an ISO version largely based on UDX for review and consideration for adoption as an ISO certified standard. It has now passed through two international audit committees, which meet once a year, for review, audit, and feedback but still must pass through three more before certification as an international standard can be issued. The third international committee to audit the standard was held October 1.

“If the ISO version of UDX is adopted as a standard language, CAD/CAM users will finally have an international standard format through which CAD/CAM files from disparate vendors can freely operate and information between the practice and laboratory can pass back and forth through this open format,” says Brown, who also is a member of the ADA working group. “This will offer all dental professionals the opportunity for enhanced and unencumbered communication.”

Having a universal file format that all CAD/CAM systems, management software programs, and devices can understand will also facilitate automating the digital production process in the dental laboratory. The prescription, with patient name, tooth number, type of restoration, material, design parameters, and any other data critical to digitally producing the finished restoration, would be either digitally submitted to the laboratory by the practice or manually input in the laboratory, and then that data would then be easily imported into and understood by any CAD and CAM process being used in the laboratory.

“Ultimately the goal is to provide interoperability and easy implementation of software and hardware systems between the practice and laboratory, as well as facilitate seamless and hands-free automation in the laboratory," Selberis says.

In the future a universal CAD/CAM language that is compliant with data exchange privacy standards will be the first big step in the maturity of digital automation and communication in the dental industry; the next will be infusing artificial intelligence into digital systems. Artificial intelligence is visible in many personal, retail, and security technologies such as voice and face recognition software, language translation programs, computer video games, Apple’s personal assistant Siri. A form of artificial intelligence is currently evident in CAD software that automatically matches patient anatomy and tooth shape to tooth libraries embedded in the software and offers restorative proposals. However, the digital tools available to dentists for capturing the patient’s oral situation have not had the advancements in software to quantify and analyze the patient’s oral condition and monitor microns of change over time. “We believe that in the future the 3D picture or digital replica of the mouth will be the initial baseline data that dentists use for assessing the treatment needs of the patient and communicating those needs to the patient, and as such, an essential component of the patient record," McMaster says. "Not only is the digital impression important as the starting point for CAD/CAM digital workflow but it is a more effective way to communicate, educate, monitor, and quantify change in the oral condition over time. The end goal is improved patient health and increased patient treatment acceptance."

This paradigm shift in the role digital impression scans play in oral care treatment was the motivation for the recent announcement of a partnership between 3M Oral Care and the Kois Center in Seattle.

“Dr. Kois and the Kois Center have been truly visionary in understanding how to utilize digital data to take the practice of dentistry to new levels,” McMaster says.

As part of this partnership, the Kois Center also announced a collaboration with with Evidentiae Technologies. Evidentiae has designed a web-based software program that utilizes accurate intraoral scan data along with the Kois comprehensive risk assessment and treatment planning principles to help the clinician provide a comprehensive report and treatment plan for the patient. The companies have partnered with a select team of Kois dentists to begin using the 3M True Definition Scanner and the Evidentiae software as an integrated system to generate a patient risk assessment and oral wellness report. While the promise of this new treatment protocol is exciting, the paradigm shift in the clinical approach will take time to be fully integrated into everyday practice given the enormous change in mindset that is required for dental professionals. Because clinicians will need to learn how to incorporate the intraoral scan into the initial wellness and screening exam, training and education will be critical. But it is an investment that both 3M and the Kois Center feel is worth it.

“Using the intraoral scan as the baseline for the patient record of the future will be the fundamental starting point for better communication, diagnosis, and treatment,” McMaster says.

1. The Radicati Group, Inc. Email Statistics Report, 2015-2019. The Radicati Group Site. https://www.radicati.com/wp/wp-content/uploads/2015/02/Email-Statistics-Report-2015-2019-Executive-Summary.pdf. Accessed August 17, 2015.

When a dental and medical surgical/restorative team approached Lee Culp, CDT, concerning a highly difficult implant case, he didn’t hesitate to say yes because he’d never worked on a project of this magnitude. The case involved a patient whose lower jaw was diseased. A section of the jaw had to be replaced by bone from the patient’s fibula. However, there were several obstacles that had to be overcome for a case that required such a high degree of communication and coordination. The first was that the physicians, surgeons, and prosthodontists were in New York City and Culp’s laboratory is in North Carolina. The second involved the digital scan data. “I didn’t know if I would be able to import and work with the digital medical files they were generating in my CAD software,” Culp says. The third obastacle was that the implants, complete with temporary restorations, were being placed on the day of surgery in the bone of the fibula before that section of bone was removed to replace the diseased section of jawbone.

“It is amazing how digital technologies have changed the way we approach, communicate, and complete a case with this level of difficulty,” Culp says. The physical distance was overcome by regular conversations among team members using GoToMeeting. Culp watched as the surgical team virtually manipulated CT scans of the jaw and leg bones to plan the precision cuts that would be needed in the fibula to replicate the section of diseased jawbone. The team then created a single digital file that would be sent for the manufacture of 3D printed surgical cut guides for both the medical and dental teams. Next came virtual planning of the position of the implants. The patient’s existing teeth had been captured using a digital impression scanner, and that digital file was overlaid onto the CT scans for Culp and the team to virtually plan where the implants should be placed and how the case would be restored. All elements of the case were assembled into a single file for creation of an implant surgical guide as well as an occlusal index. The file also was converted into STL format for medical modeling so that Culp could import it into his CAD software for prosthetic design (Figures 1 and 2). Prior to surgery, Culp designed and milled PMMA temporary restorations for a screw-retained implant bridge and delivered them to the team for fit testing once the implants had been placed in the fibula. On the day of surgery, the medical and dental surgical teams coordinated the surgeries so that the live bone segment cut from the fibula with implants and prosthetics in place could be transferred to the dental team for aligning the prosthetic and precisely setting the bone in place. “This entire case was planned and designed in a virtual environment, the implant restorations designed and fabricated using automated technologies, and all completed and delivered without the use of any physical models,” Culp says.