Digital Workflow: The Optimization of Patient Care

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ID Feature – May 2018

By Allison M. DiMatteo, BA, MPS

Digital technology continues to advance, and with those advances come opportunities to elevate clinical care. The development of a digital workflow via digital scanning and chairside milling can streamline diagnostics, case acceptance, treatment planning, communication, and restorative delivery. Inside Dentistry examines reasons why you should consider going digital and how to seamlessly and cost-effectively help your practice make the jump to lightspeed.

Introduction

Since the concept and the technologies to support it were first introduced more than 30 years ago, an estimated 20,000+ dental practices have embraced some form of a digital workflow. The cornerstone of that workflow could be digital impressions, computer aided design/computer assisted manufacturing (CAD/CAM), and/or digital radiographs. Yet, while the number itself—twenty thousand—may sound impressive, in the grand scheme of adoption of innovations, that level of penetration over three decades really wouldn’t “wow” typical investors. What’s more, of the practices that do have digital dental technologies, it’s further estimated that only about 5% are regular users on a daily basis.

“Digital dental technologies have been slow to penetrate the marketplace for many reasons, including cost and learning curve,” observes Edward McLaren, DDS, MDT, a professor at the University of Alabama Birmingham Dental School who also maintains a private practice limited to prosthodontics and esthetic dentistry. “Twenty years ago, any other technology investor would have looked at how long it would take to achieve this level of penetration and said that’s not typically the timeline they look for. They’d typically want 20% to 25% market penetration at 10 years, and more than 50% market penetration by now.”

Over the past 12 to 18 months, however, digital impression scanning has been one of the fastest growing areas of digital technology that is penetrating the dental marketplace. According to John Cox, Vice President of Technology Sales for Henry Schein Dental, this can be attributed to more dentists recognizing the return on investment that digital impression scanning yields in the form of enhanced patient experiences, more accurate impressions that result in fewer remakes and chairside adjustments, and savings that are offered by many laboratories when digital impressions versus analog impressions are used.

“Clearly the dental practice is a business, and any time you invest in something that you practice with, you have to look at its return in terms of your workflow and what it will do for your patients, because if you can provide better care, then generally that’s a good return on investment,” says Gary Kaye, DDS, of Kaye Dentistry in New York City, who notes that the return on investment from digital dental technologies is multi-effectual. “It may improve efficiency and deliver a return by saving you time in the process. It may also improve accuracy and therefore deliver a return by eliminating or reducing errors and the need for remakes.”

Benefits of Chairside Scanning & In-office Milling

According to Cox, there are significant benefits that practices could experience from workflow “automation” and optimization that eliminate the manual processes typically contributing to inefficiencies.

“Going digital can benefit all types of practices, including solo practitioners, specialty practices, multiple location practices, and large group organizations,” Cox explains. “We’ve seen all types of practices adopt digital workflows to enhance the patient experience—which drives more referrals; provide a more predictable quality of care—which drives better clinical outcomes; and improve efficiency and productivity—which increases practice profitability.”

“These days, digital scanners produce as accurate or more accurate impressions than conventional methods, while requiring less time and being much more patient friendly,” notes Clint Stevens, DDS, a private practitioner in Tulsa, OK. “Chairside milling further enhances patient outcomes, not only through the convenience of one-visit dentistry, but by eliminating many of the potential complications created by a two-week provisionalization period.”

For example, the ability to control clinical outcomes and fabricate restorations chairside allows for optimal adhesive bonding, since the optimum tooth surface to bond to is a freshly prepared one, rather than one subjected to contamination over time due to a provisional process, explains Dennis Fasbinder, DDS, clinical professor of Cariology, Restorative Sciences, and Endodontics at the University of Michigan School of Dentistry. Chairside CAD/CAM restorations have potentially the lowest rate of postoperative sensitivity compared to any other type of adhesive restoration, he adds.

Additionally, according to Mike Selberis, Chief Information Officer for Glidewell Dental, based on the laboratory’s data on returns from digital impressions versus those from physical impressions, there is a significant advantage to going all-digital. Most of the errors inherent in making plaster models are eliminated, which is especially true for single-unit and small-span bridges, he says.

By purchasing a complete chairside solution—which includes CAD software, a milling unit, and an intraoral scanner—dentists can enhance their workflow by performing same-day dentistry. Selberis explains that in this scenario, after the impression scan is captured, the CAD software proposes a restoration design for the dentist to review and adjust as necessary, prior to sending it to the milling unit, where the restoration can be milled and then seated in a single appointment.

Fortunately, because digital workflows are—by definition—CAD/CAM based, the use of all modern, monolithic materials is possible in the dentist’s office, explains Selberis. Among them is fully sintered zirconia, which doesn’t require an oven. With such a solution, a zirconia crown can be produced chairside and delivered in as little as 45 to 60 minutes from initial scan to final cementation.

From Fasbinder’s perspective, the biggest advantage is delivering ceramic restorations in a single appointment—including crowns, onlays, veneers, and implant crowns—which represents a significant time and cost savings to both dentists and patients. Chairside digital dentistry is also a process that patients undoubtedly desire, since very few people want to see the dentist more times.

“It has been documented that when patients go to the dentist even for a ‘short appointment,’ they ultimately miss at least half a day of work or need half a day of child care,” Fasbinder adds. “Delivering a final restoration in a single appointment offers much more savings to the patient than a potential 20- to 30-minute appointment.”

“In terms of process efficiency, time savings, and cost savings, if you’re able to provide a final restoration in one appointment, that makes the patient a lot happier,” observes Gregg Helvey, DDS, CDT, an adjunct associate professor at the Virginia Commonwealth University School of Dentistry in Richmond, Virginia. He adds that when you consider the overhead costs associated with a return patient visit (e.g., reserving chair-time, staff time, time going through the same protocols), a single visit restoration also makes the dentist happy, particularly because their profit is the difference between what the patient pays and their overhead. “With everything done in one appointment—without reoccurring overhead costs (e.g., multiple patient appointments, laboratory remake fees)—there’s a big savings both time-wise and money-wise.”

According to Selberis, another obvious advantage of a digital workflow for dentists is the time saved by submitting a digital impression to their laboratory immediately after scanning the patient, and the laboratory not spending a day making and scanning a plaster model. The scans can also be more accurate than traditional polyvinyl siloxane impressions, resulting in not only faster turnaround times, but also better fitting crowns and bridges—and thus fewer returns.

“Digital processes facilitate communication with the laboratory, as well as with dentists themselves,” observes Helvey. “If you are working on a very large or complex case, it’s possible to make a scan, assess the scan and preparation on a screen, send it to your laboratory, and allow the laboratory to view it to determine if any alterations are needed.”

Helvey elaborates that when preparing a tooth, dentists lose a lot of the reflective capability of the tooth structure, so they’re unable to see aspects of the tooth and preparation that they can visualize on a scanned image. Therefore, examining a preparation in 3D and digitized can actually make them a more technically precise dentist, particularly because digital scanners are very sensitive to capturing tooth anatomy (e.g., margins) that must be clearly defined.

Helvey adds that the difference between a traditional impression—which is a negative image of a tooth that doesn’t represent the preparation design until it’s poured up into a model, and digital impression scans is that the latter are much clearer and enable easier visualization of anatomical details. Many times, what the impression looks like after it’s poured is different, or there may be bubbles or voids in the margin areas that require a new impression. When you digitally scan preparations, you can see everything exactly. As a result, if dentists don’t see the margin or it’s covered with blood, they can go back, establish hemostasis, and then make their final scan.

What’s more, because many laboratories follow a modeless process, some will pass savings on to the dentist, since they didn’t need to print a model to fabricate the restoration, Selberis adds.

Numerous milling materials and restorative choices afford an abundance of opportunities to provide patients with the best treatment option, says Daniel Alter, MSc, MDT, CDT, executive editor of Inside Dental Technology. Whether the new multilayered or translucent zirconias (e.g., full-contour or layered), or one of the wealth of ceramic choices and resin/ceramic hybrid materials are used, all provide an elevated level of functionality and esthetics.

“Many CAD/CAM materials can be both hand polished and surface glazed, depending on the level of esthetic value required for the case,” explains Fasbinder, noting that esthetic outcome is more a function of fabrication than CAD/CAM technology. “CAD/CAM processing fabricates the volume of the restorations, with surface texture, contour, and shade modification influencing the esthetic outcome. More anteriorly placed restorations require surface shade customization that can be completed in office.”

According to Alter, each material possesses different characteristics that translate to different benefits for the patient. Therefore, it’s prudent for clinicians to become acquainted with these materials, or partner with a knowledgeable laboratory to make appropriate selections. Some factors to consider include cementation versus bonding, the antagonist situation, margins, shade considerations, and underlying tooth structure, he says.

Getting On Board—What’s Involved

When it comes to making the move to digital dentistry, the question is not “if” dentists will adopt digital technologies and workflows, but when. The timing depends on many variables, explains Cox. These include the expected results a dentist wants digital technologies to deliver; whether the practice network infrastructure can support the addition of new technology; and whether it is robust enough to optimize the digital workflow. These variables determine which digital technology solutions will best meet the practice’s needs and be scalable to support future growth and expansion.

For example, in the very near future, don’t be surprised to see fully integrated 3D printers added to the chairside digital workflow. With 3D printers, restoration designs are sent to a printer for manufacturing, much like they’re sent to a mill.

Therefore, Selberis advises that when purchasing a new chairside solution, it’s important to look for one that is platform-based, will allow a 3D printer to function within the existing digital workflow, and simultaneously integrate seamlessly with the laboratory. These more advanced solutions will enable dentists to work more closely with the laboratory and choose the workflow and material best suited for the dentist and patient in a particular situation.

“One distinct advantage would be the ability to send scans to the laboratory for design, which are then sent back to the dentist’s office for milling or 3D printing while the patient is still there,” Selberis explains. “This new workflow is better suited for multi-unit cases, where it might not be in the dentist’s best interest to design a larger or more complex restoration, when he or she could be seeing more patients instead.”

To go digital, practices need access to capital, Cox says. They also need to determine if they are prepared to implement another protocol or clinical change in the practice, and/or if they are focused on adding new locations versus new technology.

This inherently means that also critical to the success of technology integration and adoption is buy-in by the dental team, who should be empowered to be part of the process and actively engaged in using the technology, Stevens emphasizes.

“Once they see how positively it will affect their daily tasks and patient outcomes, it should be easy to get them on board,” Stevens says. “Even the most resistant team members should come around!”

According to Cary Goldstein, DMD, an Atlanta-based prosthodontist at the Goldstein Dental Center, dentists cannot implement a digital workflow on their own, which makes team member buy-in and training essential. He shares that in his practice, if he had to be the one to take all the impression scans, then design the restoration, and finally finish, polish, and fire the milled restoration prior to cementation, he wouldn’t be effective.

“That would take too much of my time and negate the benefits of a digital workflow,” says Goldstein, emphasizing that for him, the biggest advantage of a digital workflow is time. “With a well-trained team, I gain time by not having to send crowns out to be made or making a temporary. Because everything is completed in one visit—and it’s my team that’s designing, milling, and firing the crown while I’m in a different operatory performing another crown preparation, filling, or hygiene check—I now have more time in my schedule because I don’t have to schedule seating appointments.”

Overcoming Hurdles to Technology Integration

It’s important to remember that adopting and integrating digital technology into a practice often requires changes to both clinical and business workflows. Although they can ultimately be beneficial, such changes are disruptive. This underscores the need for dentists to choose a technology partner—not just an equipment vendor—that can help their teams navigate and support a successful implementation.

Therefore, Kaye says that when selecting technology, it’s imperative that dentists examine who the supplier who’s bringing the technology to them. The technology and its successful use and integration will require support and training, and both should be in the hands of those closest to the equipment and know it best.

“Do your research and pick the supplier that will give you the necessary and ongoing support and training you need, because they’re the ones with access to information and feedback about how the technology works, what works, and what isn’t working,” recommends Kaye. “An engaged supplier that really backs their equipment makes a huge difference and is a very crucial piece for being successful.”

Stevens acknowledges that there are many manufacturers and distributors involved in selling digital scanners and mills, each with a different approach to customer education, training, and integration. He says that perhaps the most important aspect of choosing a system is ensuring that the dentist and practice—essentially the customer—receive the best support possible in terms of training, integration, and continued customer support.

Otherwise, dentists may fail to optimize digital solutions to their fullest, says Cox. He adds that Henry Schein Dental develops and delivers a comprehensive training program to ensure dental practice teams are both competent and confident in utilizing new technology, which includes a 90-day post-installation ‘technology coach’ who partners with team members to advance their success.

“Any office that is truly committed to adopting technology will be better and more productive in less time than they ever were with conventional workflows,” Stevens says, adding that digital scanners are faster and more accurate, and that CAD software and mills have never been better or more user-friendly. “However, as with any new product or procedure added to the practice, digital scanning and chairside milling have a learning curve when integrating them into existing workflows.”

According to McLaren, that learning curve will involve tooth form and esthetics, even though CAD software tooth libraries and CAM machines do a reasonable job of designing and producing restorations of tooth-like shape and form. Dentists will still need to learn some basic restoration design skills—such as manipulating 3D models on a computer screen, as well as performing custom external finishing, staining, and glazing, he adds.

“It’s like anything else in dentistry we do that requires a certain amount of learning, adoption, implementation, and doing, refining, and improving,” explains Kaye. “Chairside scanning is just like an analog impression; nobody took one for the first time and got it right; it required learning the techniques, materials, what to look for, and how to evaluate success.”

You’ve Got Options

If you’re not ready to adopt a fully integrated digital workflow, take heart. You’re not alone; you do have options; and you can still benefit from the digital process. Dentists can continue to use conventional impressioning methods and send the impression to the laboratory, where it can either be scanned, or a gypsum model poured and then scanned.

“Once the impression or model is digitized, dentists can expect to receive a greater level of precision and marginal integrity and experience the benefits of the latest restorative materials available for CAD/CAM innovations,” Alter adds.

However, it’s important to choose a laboratory partner that specializes in digital workflows, cautions Selberis, since a well-trained technical support team can provide immediate assistance when dentists need it most, which is critical to long-term success. Laboratories that provide simple and powerful workflows and enable dentists to make the best choice when choosing how and where to make the restoration is the ultimate digital workflow solution, he explains.

“This is where I believe the Digital Dental Team—a term I’ve coined in my lectures—comes into play,” McLaren points out. “The Digital Dental Team involves the dentist and/or dental practice scanning the patient with a digital scanner and sending the digital impression to the laboratory, where the restoration is either designed and sent back to the practice for milling, or designed, milled, finished, and returned to the practice the same day if operated locally.”

Selberis believes that this is the promise of the new era—where it’s as if the laboratory is accessible inside the dental practice office, allowing dentists to make the material and manufacturing choice that best suits the needs of a particular case—theirs and their patient’s—every time.

Alter suggests partnering with a well-versed and knowledgeable dental laboratory, which can help to make transitioning into digital dentistry significantly easier and help to reduce the learning curve for achieving great results. Laboratories can also introduce innovative and collaborative efforts for patient acquisition and marketing the practice as state-of-the-art, high tech, and associated with a high-tech dental laboratory.

Conclusion

Compared to what was available 20 years ago, today’s available technologies enable much more intuitive, automated, and efficient processes, with clinically predictable outcomes that have been documented with long-term clinical success, Fasbinder emphasizes.

“Especially in the last five to six years, I think the leaps and bounds in digital technology have brought it to the point where, why wouldn’t you have technology in your practice?” Helvey asks.

However, for individual dentists and their practices, the success of any new technology implementation can be measured by asking three questions, advises Cox. Does the technology deliver an enhanced patient experience? Does the technology contribute to more predictable quality treatment outcomes? Does the technology improve practice efficiency and productivity?

“Dentists need to realize that digital scanners and milled restorations are no longer niche products—but rather the norm in today’s dentistry—and there has never been a better time to go digital,” Stevens emphasizes. “The best thing they can do is become educated on what today’s systems can offer their practice, find the solutions that are the right fit for them, and get plugged into the present and future of dentistry.”

According to Kaye, any time dentists can incorporate technology that makes processes more efficient, team-members more engaged in providing better dentistry, and dentists better dentists, it’s a win-win for the practice and for patients. He adds that today’s digital impressions and digital dentistry is no longer in the experimental state, but rather has been used routinely for many years.

“It’s a no-brainer,” Kaye emphasizes, “And there’s no reason not to embrace this technology today.”