Dr. Marty Jablow is America’s Dental Technology Coach. Due to his expertise in dental technologies, he is in high demand both as a lecturer worldwide and as a consultant to the manufacturer community. He is a member of the prestigious Cellerant Best of Class selection committee, charged with the annual selection of industry awards, and is the Chief Development Officer of Cellerant Consulting Group dentistry’s leading incubator and accelerator. Dr. Jablow has written articles for every major dental journal including his own column and video series. He is president of Dental Tech Advisors, a dental consulting company.

He received his dental degree from Rutgers Dental School in 1986 and practices in Woodbridge, NJ., and has achieved Fellowships from the Academy of General Dentistry and the International Association of Dental-Facial Esthetics. He has been selected multiple times as one of Dentistry Today's magazine Top Lecturers. He holds memberships in the American Dental Association and NJ Dental Association and is a long-time member of his county’s Peer Review Committee.

Dr. Marty Jablow

Abstract

 (CBCT) imaging is transforming the way dentists acquire diagnostic information. CBCT scans provide greater imaging accuracy and detail for better diagnosis and treatment planning, improved execution of surgical procedures, and more information for assessing pathology and outcomes.

 Traditional full-mouth radiographic series and panoramic images deliver the basics for presurgical assessments, but in many cases, they lack the detail necessary to plan and execute treatment that will yield superior surgical outcomes.

Diagnose temporomandibular joint disorders

Accurately place implants and fabricate surgical guides

Plan and assess root canal therapy and retreatment

Perform cephalometric analysis and determine root location

As its cost has diminished, CBCT imaging has become more commonplace. When selecting CBCT equipment, be sure to understand what your present and future needs are, so you can select the proper field of view (FOV). Generally, as FOV increases, so does the cost of the machine.

Once you start using CBCT, you begin to realize when the information it provides is invaluable for planning purposes. There is never an instance in which I would find less information beneficial. But there are many cases for which routine 2D imaging is sufficient, and I want to follow the ALARA principles for patient exposure to radiation. When I decide that I need 3D imaging, it is because to plan the best treatment, I need the additional details it offers. In addition, CBCT data is also important for other clinical decisions, such as determining whether a case is beyond my training and a referral for specialty care is necessary.

For me, the most important benefit of CBCT 3D imaging is determining whether an implant can be optimally placed or whether other treatment options should be explored. Routine 2D imaging (

) is always a good starting point, but when dealing with esthetic cases with multiple implants, CBCT 3D images makes treatment easier.

Why 3D CBCT Diagnostics Are Needed in Today’s Practice

The bridge shown in Figure 1 was failing, and the patient requested an implant. A PreXion CBCT scan was obtained in my practice to determine the placement and the number of implants that were possible (

). An intraoral scan was obtained for the fabrication of a temporary printed Valplast removable partial denture (RPD) (

Catapult Education, LLC is an ADA CERP Recognized Provider. ADA CERP is a service of the American Dental Association to assist dental professionals in identifying quality providers of continuing dental education. ADA CERP does not approve or endorse individual courses or instructors, nor does it imply acceptance of credit hours by boards of dentistry.

Approved PACE Program Provider. FAGD/MAGD Credit. Approval does not imply acceptance by a state or provincial board of dentistry or AGD endorsement. 6/1/20 to 5/31/24. Provider ID 306446.

Catapult Education designates this continuing education activity for 1/2 credit.

For more info on this activity, or to take the quiz and obtain your continuing education credit follow the link from the QR code or visit 

www.catapulteducation.com/course/cbct-diagnostics

The teeth were then extracted and the RPD placed. After sufficient healing, the RPD was used as a guide by placing flowable composite on the front teeth. The RPD was placed in the mouth again, and the CBCT scan was taken for additional planning (

). Merging of the 3D images allowed for proper implant planning and the printing of a surgical guide (

). The guide was inserted in the mouth, and the implants placed (

Impacted third molars are another scenario in which CBCT imaging gives you necessary data.

 Knowing how close the teeth are to the inferior alveolar nerve can make a better surgical approach possible and hopefully minimize trauma to the area and reduce the likelihood of a paresthesia (

Endodontic cases can be challenging, especially those involving maxillary molars whose roots overlap into the sinus. CBCT imaging simplifies these cases, as the number of canals and the extent of pathology can be determined before initiating treatment (

 After viewing the CBCT images, it may be evident that the tooth is not restorable because of the extent of the lesion. It is rarely possible to determine this prior to surgery using only 2D imaging.

3D CBCT imaging captures more information about the patient’s anatomy and can reveal numerous health issues.

 I like to say that you never know what you may find while viewing a CBCT scan.

Here are 2 other findings I didn’t anticipate. Figure 10 shows a lymph node calcification. Figure 11 is from a patient who presented with pain, and pathology was found in the sinus, along with perforation of the buccal plate.

As you can see, these patients walk through your door every week. A CBCT scan takes the guesswork out of diagnosis and treatment planning. It can also help patients better understand treatment recommendations. We can show them the details and demonstrate why something is necessary or why a requested treatment won’t be possible. With benefits to clinicians and patients alike, it’s clear CBCT imaging plays a key role in the present and future of dentistry.

Shukla S, Chug A, Afrashtehfar KI. Role of cone beam computed tomography in diagnosis and treatment planning in dentistry: an update J Int Soc Prev Community Dent. 2017;7(Suppl 3):S125-S136. doi:10.4103/jispcd.JISPCD_516_16

Hermann L, Wenzel A, Schropp L, Matzen LH. Impact of CBCT on treatment decision related to surgical removal of impacted maxillary third molars: does CBCT change the surgical approach? Dentomaxillofac Radiol. 2019;48(8):20190209. doi:10.1259/dmfr.20190209

Patel S, Brown J, Pimentel T, Kelly RD, Abella F, Durack C. Cone beam computed tomography in Endodontics — a review of the literature. Int Endod J. 2019;52(8):1138-1152. doi:10.1111/iej.13115

Dief S, Veitz-Keenan A, Amintavakoli N, McGowan R. A systematic review on incidental findings in cone beam computed tomography (CBCT) scans. Dentomaxillofac Radiol 2019;48(7):20180396. doi:10.1259/dmfr.20180396

Articles

Earn up to 1/2 Continuing Education Credit after reading this article about the clinical applications and benefits of 3D CBCT technology.

When I started searching for a CBCT system, I had a multiplicity of choices. Every machine touted the ability to produce stunning images and offered incredible product support. But in the end, the decision was not all that difficult.

I needed CBCT for better implant planning. For many years, I and a periodontist in my office had placed implants freehand. Occasionally, we needed advanced planning and then we worked with a mobile CBCT service. This was fine, but recently I brought an oral a surgeon into the practice for advanced implant placement and third-molar removal, and then an in-house CBCT system became an absolute necessity.

We purchased the PreXion3D Excelsior PRO, and the detail it captures is all the information we need for better treatment planning—and thus for better treatment outcomes for our patients.

After reviewing the available systems and deciding on the Excelsior, the first thing we needed to determine was whether it would fit in the office.

This was not as easy to figure out as it seemed at first. Even though the office had been built with a dedicated room for CBCT, we needed measurements and the equipment’s placement had to be adapted to the room. The good news is that the Excelsior’s footprint is standard. It was delivered in pieces on pallets, so it was interesting to watch it being assembled, placed in the room, and wired up to the acquisition computer. The assembly didn’t take long, and the machine was up and running in no time.

A straightforward training session had already been scheduled for the entire staff. Because there are no licensing fees for additional computers, all of ours had access to the images, which was a great advantage.

In addition, the system features a dedicated panoramic imaging option, which allows us to capture 2D panoramic images and external bitewings for patients who have difficulty with intraoral radiographs.

Something else I needed to determine ahead of time was whether Excelsior would be a good fit for my office in terms of the available fields of view (FOV). The larger the FOV, the more data one must interpret, so having the flexibility to scan at the correct FOV for each individual case was very important.

I do endodontics and some retreatments. A 5x5 scan with high resolution makes it easier for me to find fractures and extra canals before beginning treatment.

Most of our scans for implant planning are 10x8 cm, which allows us to view both arches in one image. We use the 15X8 cm FOV option when we need third-molar visualization. We can also adjust the scan mode to limit the radiation according to ALARA (as low as reasonably achievable) principles. This way we use less radiation when validating the location post-implant insertion than we do for planning the placement.

Speed is another key factor. With the Excelsior, standard scan mode is under 10 seconds, rapid mode scans in just over 5 seconds, and a panoramic image takes 10 seconds. This is important because patients must remain still during scanning, so the faster the acquisition, the cleaner and better the image you have to diagnose from.

The PreXion Excelsior PRO has a 0.3 mm focal spot and 70 µm voxel size. This allows the CBCT system to achieve superior imaging, which is what you really want it to do in the first place.

Image quality is of course important, but you also need to be able to afford the CBCT. I’ve found that it takes only a few 3D scans or panoramic radiographs each month for the PreXion Excelsior PRO to pay for itself. Check with your accountant about taking the proper tax deductions to keep acquisition costs down.

The CBCT system met my expectations, but I knew the hardware needed to be paired with quality software, and with a platform including numerous useful features, PreXion was able to deliver there as well.

Multidata mode loads multiple patient scans on a single screen. This can be used to synchronize pre- and post-operative scans and detect differences slice-by-slice, which is ideal for looking at potential pathology.

The system features with presentation capabilities that quickly capture 3D animated video clips for use in patient education, case presentation, and for visuals at lectures. This allows me to increase case acceptance through improved patient understanding.

Collaborative tools allow the system to automatically save 3D image reports in MS Word and attach them to the practice management record for each patient. Then it’s easy to work with referring dentists by providing them with images via email, CD-ROM, or USB drive. The other clinician can access the images with a sample viewer application.

The remote access capability allows me to work on cases from home or a satellite office without connectivity delays. I can even lead virtual online treatment planning meetings remotely with PreXion3D.

Another nice features of these scanners is they don’t require computer hardware upgrades or slow down network bandwidth. This is a big deal as it lets everyone have image access, and loading time is very fast.

The system’s extensive implant library is an absolute necessity for implant planning. Combine this with intraoral scans, and the planning becomes very simple.

The system is designed to help you save time with over 20 preset 3D volume rendering templates and the ability to customize your own to get images in whatever format you prefer.

The slab feature allows you to see inside structures while rotating the image, and you can even cut away structures to see exactly what is pertinent to your study.

I have had the PreXion Excelsior PRO for a little over a year, and I’ve had no complaints from any of the doctors about image quality. Likewise, I’ve had no hardware issues at all. Everything from the CBCT to the computer works. But if we do have a problem, I’m comfortable because the system includes a best-in-class warranty.

Overall, we have been very happy with our PreXion Excelsior PRO CBCT purchase. It has exceeded our expectations and allowed us to do better dentistry.

[SPONSORED] Marty Jablow, DMD shares his experience with the PreXion3D Excelsior PRO CBCT system.

Test Drive: Amazing Imaging for Your Diagnostic Needs

Most of us use the cloud for everyday tasks and it can be accessed wherever there is an internet connection via a computer or smart device. In today’s digital dental office, the cloud is driving tech-enabled change so your staff can work more efficiently. The cloud is where integration and software connect, promising a bigger future. I sat down with Jonathan Penchas, DMD, of Midtown Dentistry in Houston, Texas, to discuss the advantages cloud technology has brought to his practice.

Open-architecture works with practice management software and imaging devices

Centralized image storage and 
third-party image sharing

“This is software as a service,” Penchas says. “Images are acquired locally, uploaded to a remote server, and then stored in a single cloud environment. There is no longer a need for multiple databases as all of your 2D, 3D, clinical photos, and intraoral scan files can be stored in one database. Images are stored in an open format that allows you to both store and retrieve images from a webpage or any DICOM-compatible imaging program over a secure internet connection.”

Penchas uses XVWeb by Apteryx Imaging for his cloud-based imaging. According to Penchas, he made the switch to XVWeb for three reasons:

Accessibility and remote treatment planning

While not all imaging systems utilize an open architecture, XVWeb does. Open architecture means you have the freedom to choose the best practice management and imaging devices for your office now and in the future. You are not locked into a limited upgrade path based on a manufacturer’s decisions.

The same holds true with file formats. You can store and view your images in standard DICOM format, which is the free open source way images are acquired and shared by practitioners. It is not necessary to convert file formats. This makes HIPAA-compliant sharing of all images simple and easy, as everything needed to do so is included in your monthly fee.

Why was open architecture an important aspect of your decision to move to the cloud?

“An open platform is a wonderful thing. If I ever want to switch my practice management system or use a different brand of sensor or [panoramic] unit, I can,” Penchas says. “While I love the systems we have currently, the idea of being independent gives me a level of comfort in being able to use whatever technology we decide fits our practice best. If that changes down the road, we can adjust one aspect of our systems without wholesale changes.”

“Cloud-based imaging utilizes secure, remote servers so your database does not physically exist in your office. Each individual in a practice has controlled access to the imagining database for HIPAA compliance, so we know exactly who logged in and viewed which images in the log,” Penchas says. “The cloud servers are backed up in multiple locations for data redundancy so you can be assured that your data [are] safe.”

On the topic of security, he says he has seen colleagues lose data to natural disasters, ransomware attacks, and faulty data backups.

“I personally know practices that had their data stolen in ransomware attacks, where they were extorted for $20,000 by hackers to get their data back. Here in Houston, Hurricane Harvey flooded many dental practices. Friends with on-premise data storage lost their servers, and even practices that had off-site backups with local IT groups were impacted because those remote servers were lost to flooding, as well,” Penchas says. “With XVWeb, we have our data stored in data centers with redundancies built in, so we are confident that our data is safe, regardless of what might happen locally.”

How do accessibility and remote treatment planning affect your practice?

“Our practice, Midtown Dentistry, has five locations, and cloud imaging allows me to aid in treatment planning for all of our practices remotely. As a prosthodontist, I can use XVWeb to quickly view 2D and 3D images acquired from any of our practice locations,” Penchas explains. “So, if one of my colleagues across town needs to consult with me or requests a pricing estimate for treatment, I can easily log into XVWeb, view the images, and make an immediate recommendation. This provides great efficiency for both our clinicians and patients.”

A cloud-based imaging database can be accessed by any doctor or staff member any time, anywhere. Multiple staff members can access an image at the same time, even from different locations. All you need are your login credentials and an internet connection. The access is device-agnostic, meaning you can use any secure web browser on any platform to view your images. For example, you could view images on your mobile phone if you get an emergency call while at the beach.

Do you have an example of using cloud technology to share?

“XVWeb makes case collaboration with our associates more efficient, which expedites patient care. Here is an example of a recent implant placement utilizing XVWeb for treatment planning:

Cone beam computed tomography (CBCT) was taken in one of our remote offices prior to discussing implant placement with the patient 

A remote, real-time diagnosis was performed to determine the viability of the proposed treatment plan and whether there was need for a sinus lift procedure. This collaboration occurred remotely via XVWeb 

Other findings were noted during the reading of the CBCT that could potentially affect future treatment. The left maxillary second molar root is in the sinus, and the tooth also has an MB2 canal with an apical lesion. The canal was marked on the CBCT in XVWeb so the treating dentist is aware of it to ensure the issue is addressed 

Implant planning was performed in the cloud via XVWeb. A third-party software was used to design a surgical guide, which was sent to a lab for fabrication.

Follow-up radiographs and treatment planning information are saved in XVWeb for documentation and future use.

Case Study

Cloud-based imaging takes advantage of technological advancements that are not possible with on-premise solutions. With the rise of teledentistry, which has increased due to the coronavirus disease 2019 pandemic, cloud-based imaging is just another piece of the remote dentistry puzzle. It allows you to view images remotely and securely collaborate with other dentists and specialists.

I would like to thank Penchas for his input and insight into cloud imaging technology. It’s great to hear real-world experience that can be used when deciding if your practice is ready to make the jump into the cloud. If you would like to connect with Penchas, email him at drpenchas@midtowndentistry.com or visit www.midtowndentistry.com. 

Dr. Jonathan Penchas is a prosthodontic specialist and founder of Midtown Dentistry in Houston, Texas. He received his DMD degree from Hebrew University and completed his specialization in prosthodontics at Louisiana State University. Penchas also holds a Master’s in Education from the University of New Orleans and completed a fellowship in dental oncology and maxillofacial prosthetics at M.D. Anderson Cancer Center in Houston. In his free time, Penchas enjoys spending time with his family, traveling, beekeeping, and SCUBA diving.

XVWeb® by Apteryx Imaging offers secure, open architecture cloud-based treatment planning. 

How to use cloud-based imaging to work more efficiently

	When working with emerging technologies and new companies, my thoughts are always on the future of dentistry. While it’s fun to ponder what could be or what’s coming, I felt that getting the opportunity to discuss what’s current with one of the most knowledgeable experts in the industry would bring great value to our readers.

	That’s why I sat down with my good friend, Dr. Marty Jablow, “America’s Dental Technology Coach” and a panel member for the 

Cellerant Best of Class Technology Awards

, to talk about dental technology as it is today.

	LS: What are the latest trends in dental technology?

: The latest trends involve digital integration so that we can merge various pieces of digital technology to achieve a more efficient workflow and better restorative product.

	We’re now using CBCT and intraoral scanners to integrate data sets to achieve things that just a decade ago were considered difficult or impossible. Another trend is using artificial intelligence (AI), as it improves diagnosis, treatment planning and the use of scanners.

	LS: What are your feelings about the use of artificial intelligence (AI) in dentistry?

: Artificial intelligence is in its infancy, but it will totally change the way many things are done in dentistry. I’ve had the opportunity to see and use some of these technologies.

	The use of AI in intraoral scanning can eliminate elements such as blood, gingiva and retractors from the scan. This makes scanning easier, more accurate and efficient. It tells you where things are missing and how to better catch the missing data in the areas you need to rescan.

Read more: How to invest in the right technology for your practice

	The use of AI in diagnosis may be the most game-changing. You can see caries and determine whether it may be best to watch or restore. You can see lesions on radiographs and get differential diagnosis. And that’s just the start!

: Dental technology is continuing to evolve. The big thing now is digital workflow. In reality, we’ve had a clinical digital workflow for decades.

	The digital workflow started with the first CAD/CAM systems, such as the early CEREC systems. What we’re seeing is the evolution with the lower cost of the components such as CBCT, intraoral scanners, mills and 3D printers. Lowering the barrier to entry along with the lower cost of the high-horsepower computers makes using a digital workflow within reach of most dental offices.

	LS: How are people using intraoral scanners?

: Intraoral scanning is taking off in dentistry now that the prices are starting to drop. There are currently scanners on the market for less than $20,000. These are high-quality scanners that can produce scans in standard file formats that can be easily shared in any software for diagnosis, treatment planning and restoration design.

	Through the use of intraoral scanners, difficult procedures, such as retrofitting a crown to an existing RPD, become easy. Determining occlusal clearance involves using a computer to visualize where to further prep a tooth, rescanning only that area of the tooth and sending it to the laboratory for fabrication of the crown.

	The best part is the number of impression retakes is nearly zero and the number of remakes is greatly reduced. I find viewing your preparations on a large computer monitor and marking your margins for the laboratory makes the final restorations much better, as you become better at preparing teeth.

	Intraoral scanning also reduces the time it takes to get your prosthetics back from the lab. There’s no longer any transit time to the laboratory, saving days in the process. In many cases, simple crown and bridge or implant cases are started the same day and are returned to my office in less than a week. The fit is usually better and the time it takes to insert the prosthetics is greatly reduced.

	The only bottleneck is scheduling the insert appointment. If a temporary crown or small bridge is inadvertently dislodged, the insertion is normally done as a side-booked event with the final prosthesis, as it’s already in the office. The patient is happy and it frees up a scheduled appointment time.

Trending article: Big data in small places

	Intraoral scanning is also being used for both full and removable dentures, fabrication of orthodontic appliances, fabrication of aligners in the office and sleep apnea appliances.

	LS: How does cone beam integration fit into the digital workflow?

 CBCT has changed diagnostics for surgery, implants and endodontics. Enhanced diagnostics lead to better outcomes. It’s no surprise this makes the patient and dentist happier.

	I’ve seen the benefits with better implant placement making the surgery more predictable and with better emergence profiles. Endodontic CBCT diagnostics makes it easier to see missed canals and fractures, along with the emerging use of guided endodontics. Just as guided surgery is improving implant placement, look for similar benefits in endodontics.

	LS: Tell me about CAD/CAM and 3D printing

: The ability to produce all types of treatment guides and aligners in-house is transforming dentistry. We all know you can mill a restoration or implant surgical guide. The transformation is happening because of 3D printing.

	Many printers are less than $5,000 and can provide a multitude of benefits to a dentist. You can print models to make in-house aligners, implant guides and night guards, or try-in dentures before adjusting and scanning so that the final denture is an exact match. And, you can do all of this for a fraction of the cost of lab-made prosthetics. However, there’s a learning curve and your assistant will need to be doing more lab work, so include that in your cost evaluation.

	The biggest part of 3D printing is the continued development of resins. There may be limitations on the long-term life of 3D-printed dentures and night guards, but it may be mitigated by the ease and reduced costs to just make another one. There are esthetic limitations too, but all of this will resolve over time as the printable resins improve, just as composites have evolved.

How current trends are affecting everything from treatment planning to in-house capabilities.

The current state of tech in the dental industry

	Some of us remember Will Robinson’s loyal robotic pal in the “Lost in Space” series of the 1960s. Others will trace the sci-fi vision of intelligent autonomous machines to the day Skynet became self-aware and turned on humanity in the “Terminator” films.

 (AI) and the official pursuit of intelligent machines in the scientific community actually dates to a 1956 conference of researchers from Dartmouth and IBM.  

	Today’s AI is invading our everyday lives, albeit in more subtle ways, such as digital assistants like Alexa and Siri. And now, AI in dentistry has arrived! 

Trending article: The future of digital dentistry

	Consider a daily task that we as dentists view as routine and relatively simple: finding caries on 

. In fact, in doing so we are “processing” conversations with the patient, the patient’s history, complex and nuanced radiographic images, and our direct intraoral exam. We’re also leveraging our training, which includes our dental education and having read thousands of radiographs over years in practice. Even so, it’s estimated that our misdiagnosis rate of caries from X-rays may be 20 percent or higher. 

	For machines to perform tasks such as reading 

, they must be “trained” on huge data sets to recognize meaningful patterns. They must be able to understand new information in the form of spoken language, written text or images with proper context and nuance. Finally, they must be able to make intelligent decisions regarding that new information and then learn from mistakes to improve the decision-making process. In order for an AI system to have a practical benefit in the real world, all of this must happen in about the same time that a human being can perform the same task. Until very recently, applications of AI on a broad scale weren’t technically feasible or cost-effective, so the reality of AI hasn’t yet matched the possibilities. 

	Whatever the technological challenges, machines do offer some clear advantages. Computers aren’t biased. As humans, we come with innate biases and we may judge things prematurely. Computers consider only the data being provided. Machines also don’t get tired. We can work for four or five hours straight before getting fatigued; machines work 24/7 without coffee breaks. Another advantage is that machines don’t get bored. The tasks that we gladly offload are monotonous and repetitive. Finally, machines are fast. While current AI systems are largely one dimensional based on the specific task for which they are trained and programmed (e.g., read radiographs and predict the locations of caries), they’re often far faster at that task than humans.

Trending article: Technology may seem scary - but better results are worth it

	The last five years have marked the modern era evolution of AI, which is being ushered in with tremendous hype and investment. Big data and cloud computing have provided ready access to the large data sets required to train intelligent systems. All that data requires vast amounts of storage, which has become not only cheap but also fast in terms of data retrieval. 

	New York Times tech author John Markoff reported on another breakthrough that came out of a 2011 project called 

, which applied “deep learning” methods to the challenge of extracting meaning from 10 million YouTube videos images. Ironically, once set free to surf the internet, Google Brain did what its human counterparts do every day - it searched for (and successfully found) cats. What’s astounding about this accomplishment is that scientists never told the machine, “This is a cat.” By using deep learning, Google Brain created an abstract construct for cats based on image recognition. 

	Deep learning, the most cutting-edge AI technique in the broader field known as machine learning, uses layered neural networks patterned after the human brain.  Traditional machine learning techniques rely on handcrafted rules defined by human domain experts and don’t improve with larger data sets. Deep learning creates its own rules that improve with additional data, making it well suited to interpret the unstructured data required for advanced applications such as self-driving cars, predicting earthquakes, and disease detection, diagnosis and treatment recommendations in medicine. Dentists actually have access to a deep-learning AI platform for detecting caries right now. 

, in the late stages of clinical evaluation, allows any licensed dentist to sign up as an investigator and utilize the system. 

	The only drawback to deep learning at the time of the Google Brain project was that it called for tremendous computing resources. Finding cats on the internet required 2,000 CPUs housed in climate-controlled data centers. In a moment that has been called the Big Bang of AI, researchers equaled the deep learning capabilities of those 2,000 CPUs using 12 NVIDIA Graphical Processing Units (GPUs). It turns out that the graphics chips that enable today’s ultra-realistic computer games also provide the speed and processing firepower to fuel a revolution in artificial intelligence systems. (As a side effect, gamers have been frustrated by backorders and shortages as the industry has snapped up NVIDIA’s chip supply, which is also used for mining cryptocurrency). 

	Healthcare in general is a very natural customer for artificial intelligence applications. 

After conquering the television game show “Jeopardy” in 2011, IBM’s Watson

 has gone on to a second career in medicine. Oncologists at New York’s Memorial Sloan Kettering Cancer Center have recently trained Watson to help fight cancer. While the program is still in the early phases, the machine already does very specific, monotonous and time-intensive tasks extremely well. For example, Watson can read a half million medical research papers in 15 seconds and, with deep learning, can recommend diagnoses and the most promising treatment options. 

With the ability to analyze vast numbers of diagnostic images such as X-rays, CT scans and MRIs, systems like this can point doctors and radiologists to the most probable areas of concern, increasing both the speed and probability of detection. And now with the FDA creating regulatory pathways to encourage developers of medical decision support software, analysts predict that the use of artificial intelligence in healthcare will grow tenfold in the next five years. 

	As noted earlier, the Dentistry.AI team has a platform for caries detection that’s in the final stages of clinical evaluation. Active development began just over two years ago and the engineers quickly learned that teaching a computer even this singular dimension of clinical dentistry isn’t easy. Yet there has been significant progress toward a clinically relevant predictive assistant for the dental practice. 

	In a recently published study, they presented the results of a man vs. machine 

 challenge that pitted three practicing dentists against Dentistry.AI in evaluating 500 bitewings. The machine outperformed the dentists in “sensitivity,” which measures the proportion of caries correctly predicted when compared with total caries present in ground truth. The dentists won the day in “precision” (the ratio of correct predictions versus total predicted caries sites), although the machine was comparable to one of the three dentists in precision as well. Let’s call it a tie for now, although the system continues to learn and improve. Commercial availability of a reliable caries detection tool based on deep learning artificial intelligence appears likely in the next 12 to 24 months. Applications for detecting 

 and the bone loss that accompanies it aren’t far behind.

, interpreting cone beam images is another area in which AI can boost productivity. At this point, analyzing cone beam data requires a specific level of training and expertise. This analysis can be time consuming, involving sifting through hundreds of image slices. With AI, the entire process of interpretation can be automated to assess the image as a whole to detect dental pathologies more quickly and accurately. Clearly, the stage is set for the rapid proliferation of truly impactful applications of AI in dentistry over the next year or two. In 10 to 15 years, the use of AI-based technologies in the practice will be as commonplace and pervasive as practice management and imaging systems are today. 

Trending article: The future of dental practices

	With technological obstacles falling and research turning to development, we’re certainly on the threshold of a range of AI-enabled tools for dentistry. We’ve already seen recent product introductions incorporating elements of artificial intelligence and machine learning (AI/ML). DEXVoice, launched at the Chicago Midwinter Meeting, is a stunning technology enabled by natural-language processing (NLP). Developed by 

, the digital assistant replaces traditional point-and-click interfaces with simple and quick voice instructions (“Show me the last full-mouth X-ray.”). Also recently announced was a machine learning-based schedule optimization program called MMG ChairFill. This program interfaces with your practice management and marketing systems to proactively schedule unfinished treatment and launch new patient marketing campaigns based on profit maximization algorithms. We’ll continue to see AI rapidly employed in the practice management and growth arena.

	With the newest capabilities enabled by deep learning techniques, AI will begin to impact dentistry on a clinical level as well. First-hand experience with development stage technologies (i.e., caries detection) has already demonstrated AI’s potential value in everyday practice. We’ve confirmed that these tools can recognize things on images that even the most experienced dentist may otherwise miss. Furthermore, we’ve seen the results returned in near real time, fast enough to be incorporated into a busy practice workflow.

	In the very future, we foresee deep learning analysis tools for images, assisting in diagnosing and treatment planning of periodontal disease by enabling early detection of bone loss and changes in bone density. Detection of peri-implantitis and early intervention is a likely benefit in implant dentistry. In orthodontics, more sophisticated predictive models for tooth movement will likely enhance digital treatment planning. Applying deep learning image analysis to oral cancer will lead to earlier detection and more accurate diagnoses with lifesaving implications. 

	The apocalyptic sci-fi fantasy that these machines and systems will replace us as dentists is nowhere near reality. It is, however, certain that they’ll soon make us better dentists by providing more data points for our clinical decision making. 

	For technology enthusiasts, our advice is to strap yourself in - there is an incredible voyage just ahead!

	1 White SC, Hollender L, Gratt BM. Comparison of xeroradiographs and film for detection of proximal surface caries. J Am Dent Assoc. 1984;108:755-759.

	2 Captain, Sean. Paging Dr. Robot: The Coming AI Health Care Boom. Jan. 8, 2016. https://www.fastcompany.com/3055256/paging-dr-robot-the-coming-ai-health-care-boom

While you may think sci-fi and imagination when you hear about artificial intelligence, the future of AI in dentistry is very, very real.

The future of artificial intelligence in dentistry

	Each month, Dr. Lou Shuman consults with a dental technology specialist to discuss the latest developments in digital dentistry, data security, social media trends, SEO strategies, website optimization, online reputation management, marketing and more. 

	This month, Dr. Shuman sat down with Marty Jablow, DMD to discuss the future of digital dentistry, and how it will affect dental practice workflows and diagnostics.Where is digital dentistry heading in the dental office in 2017?

	The progression continues. Front office staff are still migrating to the paperless office but are now incorporating many more online digital technologies. We’ve gone from just reminders to online reputation management, reviews and overall office efficiencies and production goals. The back office continues to evolve with patient treatment enhancements, such as digital caries detection and diagnostic devices, to digital impressions, CAD/CAM and 3D printing.

Trending article: 5 new workflows that are now possible

	Where should dental practice front offices be right now with their digital workflow?

 is really about efficiency. What we need to do is increase the efficiencies so we don’t do work that bogs down the front office. The easiest examples are online reminders for patients about their appointments. But, we need to incorporate other things such as digital delivery of new patient documents, since we know how many times that new patient visit gets delayed because the patient needs to fill out paperwork. Then we have the transcription issue from paper to digital to get the information into the computer. Scanning documents into the practice management software reduces the wasteful time of filing papers into charts. 

	The biggest detriment for change in the front office is shaking off “we always did it that way” mentality. There are so many technologies to make the front office much more efficient but dental staff and the dentist may be getting in their own way. Go online and see what other offices are doing in the move towards the paperless office. You need to take the baby steps which many of already done by incorporating digital radiography now it’s just about the chart notes. The most underutilized asset in a dental office is the practice management software. Find ways to maximize its use.

Trending article: Exploring today's digital dental workflow

	What’s new in digital dentistry diagnostics?

	Digital diagnostics continues to grow. Digital radiography is now mainstream, and about 80 percent of the offices in the US have gone digital. Caries diagnostics continue to evolve with various devices making caries easier to monitor and diagnose. 3D imaging is gaining ground in the GP dental offices. The prices have come down and we see a lot more competition in this space. 

	We are seeing greater adoption as we are finding more uses for this diagnostic information. CBCT is not just for 3rd molar removal; it has evolved into a tremendous way to plan implants, examine teeth with endodontic problems, and assist in orthodontics and sleep apnea treatment. Intraoral scanners are now being used as part of the diagnostics. Being able to merge CBCT Dicom sets with intraoral scanning STL file scans allow more precise implant and orthodontic planning. We can now see what effects our treatment can have on the TMJ before we start treatment restoring arches.

	The more information we acquire and the greater the data set for each patient, the better treatment planning. The better we treatment plan the more predictable our outcomes will be.

	The big buzz is about the digital dentistry workflow. What does that mean in 2017?

	At the 2017 ADA conference in Atlanta, the Cellerant Best of Class Technology Lectures will attempt to answer many of those questions. We will be discussing many aspects of the digital dentistry workflow. The problem is there is no set definition what a digital dentistry workflow is. It depends on what equipment you use and what the ultimate end game is. For most, digital dentistry means an intraoral scanner. So, instead of taking a conventional impression, you use an intraoral scanner to acquire a 3D image of the prepared tooth and then upload the information to the lab. The benefits of these digital impressions are increased accuracy, easier inserts and reduced costs. In many cases, you get back a crown in a box as there is no model and the entire process is virtual. This increased efficiency results in turnaround times of under a week from many dental labs. 

	Some others don’t consider that digital dentistry unless you add an in-house restorative component and that means CAD/CAM. There are now more choices for in-office milling than ever before from CEREC, Planmeca, Glidewell and Roland. These various mills will allow you to complete in-office restorations. The costs and mills will be based on the different material types you want for your final restorations. It is now possible to mill composite, eMax and zirconia in your office. 

Trending article: The latest advancements in digital dentistry

	What is on the horizon for digital dentistry?

	That one has an easy answer and it is 3D printing. 3D printing will transform dentistry. It’s already started. Printers are already producing implant surgical guides, implant restorative setups, orthodontic aligners and retainers, dentures, nightguards and even temporary crowns.  Lower cost printers are now within reach of many dental offices. That means we can produce these printed devices in our offices on demand. Treatment can be started sooner. We can now print surgical guides for implant placement making the procedure much more predictable enabling more dentists to place implants. 

	Orthodontic aligners can now be reliably printed at much reduced costs and no more need to worry about cost of corrections. All of this will take some training and you will have to learn some software. Go try it out as BlueSkyBio has implant and orthodontic software available for free just go download and play with it. 

	The biggest jump will be as the dental printing materials evolve. As the companies develop more and better materials the ability to produce varied restorative options will grow. The cost of the printers will decrease and 3D printers will become a standard piece of dental equipment






Dr. Lou Shuman and Marty Jablow, DMD, discuss where digital dentistry is headed-and what it means for dental practices.Each month, Dr. Lou Shuman consults with a dental technology specialist to discuss the latest developments in digital dentistry, data security, social media trends, SEO strategies, website optimization, online reputation management, marketing and more. 

The future of digital dentistry

 is an ORganically MOdified CERamic. It is a combination of inorganic (ceramic) and organic materials.

s are are pre-polymerized molecular groupings that create unique properties within the resin matrix that translate to enhanced properties offered by the restorative material. They are very biocompatible because they have no residual monomers.

Related reading: VOCO introduces Admira® Fusion biocompatible nano-ORMOCER® direct universal restorative

 direct restorative material. Using silicon oxide for the nano filler along with the glass ceramics, 

 has achieved the world’s first all ceramic-based restorative material. Due to the high degree of cross-linking between the large pre-polymerized ORMOCER

 groupings within the ORMOCER®resin matrix and the various silicon oxide-based glass filler particles, Admira Fusion’s nano-ORMOCER

 technology offers enhanced physical properties that go well beyond what conventional modern composites have offered.  

	This all ceramic-based restorative has no classic monomers, BisGMA or other substances released during polymerization, making Admira Fusion very biocompatible. Using pre-polymerized materials within the composite resin reduces volume shrinkage to an extremely low 1.25 percent and reduces the shrinkage stress to 3.71 MPa. With this low volume of stress, there is enhanced marginal integrity, and you will see longer-lasting restorations. Admira Fusion is 84 percent (w/w) filler, imparting an increased surface hardness and making the shades very stable and better able to withstand occlusal forces.

More from VOCO: Easy-to-use VOCO materials allow for natural-looking esthetics

	What are the indications for Admira Fusion? It can be used just about anywhere you would use a composite: simple Class I or II preparations, Class Vs, repairing porcelain veneer, or correcting defects in temporary crown and bridge material. It is easy to use and has a non-sticky consistency and great adaptation to the cavity walls when placed in standard 2 mm increments. Not only can it be used in the same way as a universal composite, but Admira Fusion comes in 10 VITA

¹ shades along with opaque dentin shades and four special shades for those unique situations. It takes a quick 20-second cure with a standard 500 mW/cm² curing light and 40 seconds for opaque shades. For those areas where sculpting is important, take your time as you have more than three minutes before natural light will cure the material. Admira Fusion polishes quickly and simply to a high luster.

Related reading: Easy-to-use VOCO materials allow for natural-looking esthetics

	But, what about bulk filling? VOCO has you covered there, too, using the same nano-ORMOCER

 technology and incorporating it into an all ceramic-based bulk fill restorative material called 

. The restorative is easily placed as a base in deeper preparations to save time with the same low 1.25 percent volumetric shrinkage. This bulk-fill material allows the clinician reliable placement in 4 mm increments. It comes in a single universal dentin shade with a desirable chameleon effect, which you then have the option to cap off with the Admira Fusion creating a direct, bulk-filled, all-ceramic-based restoration.

	In one case, the patient presents with mandibular right first premolar with an open contact and a defective composite restoration. The tooth was anesthetized using a Milestone STA machine using buffered 4 percent Septocaine with a PDL injection. The tooth was isolated with a 

 and the composite and decay were removed. A Triodent sectional tab matrix band was placed along with a white V-wedge. The V-Ring was placed to establish proper contact.

More from VOCO: How to complete a direct restoration with VOCO's Futurabond U [VIDEO]

Learn how to use this new material in a patient with mandibular right first premolar with an open contact and a defective composite restoration.