Laura Dorr is the former executive editor of DPR's Modern Dental Network and a regular contributing author.

Laura Dorr

LightForce uses 3D-printed ceramic polycrystalline alumina brackets that are completely customizable to suit individual needs. The brackets are available in a variety of slot sizes as well as bidimensional configurations.

As the son of an orthodontist, Alfred Griffin, DMD, PhD, co-founder and CEO of LightForce, has a deep understanding of both the dental industry and the field of orthodontics. And even as an orthodontic resident, he wanted to bring positive change to his chosen specialty. He didn’t want to reinvent the wheel, but he believed that the wheel wasn’t rolling as efficiently as it could and needed some improvements—specifically, advances in digital workflow and 3D printing.

At Dr Griffin’s practice, only about 20% of patients were getting clear aligners, and he was frustrated that there wasn’t a digital workflow for the 70% to 80% of cases that needed traditional braces. He found that those patients could not be treated as accurately as clear-aligner patients because information about braces was obtainable only visually. It became obvious to him that better technology was needed for braces. Because he needed the type of data that was easily provided by the software that came with customizable clear aligners, he began uploading every braces case to his clear-aligner software to map all the details, from jaw angles to occlusal contacts to whether there was a need for interproximal reduction.

“Clear-aligner software was the first window into what a fully digital workflow could look like in orthodontics, but we were missing the largest segment of the market, which is braces,” Dr Griffin says. “There’s a lot of data that goes into every orthodontic patient that is impossible to learn just by line of sight, a mirror, and loupes. A digital process adds tremendous value, not just to the practice workflow and efficiency, but also to outcomes for the patient.”

Dr Griffin’s practice is located in Boston, Massachusetts, largely considered the global epicenter for 3D printing and CAD software—both essential for the scaling of mass customized orthodontic appliances—and it was that software that addressed the main challenges to digital growth.

“We’ve just always been limited by the technology of the day,” Dr Griffin explains. “I like to think if the people who originally invented the straight-wire appliance 40 years ago had access to similar technology, they would have done the same thing. The challenge has always been the execution.”

Thanks to advances like 3D printing and cloud-based CAD technology, however, it was possible to customize braces for patients, Dr Griffin points out. Essentially, orthodontists would be able to print customized brackets in the same way that clear aligners are printed to fit each patient, rather than having the one-size-fits-all brackets that were previously being employed.

The idea was there, and the manufacturing technology was ready and waiting. Dr Griffin’s next step was to figure out how to turn his idea into a reality.

“I certainly did not have a lot of business training in dental school,” he says, laughing. “I knew it was a good idea, but I needed to find someone who had the expertise to implement it.”

He found it in Lou Shuman, DMD, CAGS, an orthodontist and founder/CEO of Cellerant Consulting. Dr Shuman had a reputation for knowing a good idea when he heard one.

“It didn’t take Lou 2 seconds to say, ‘This is a great idea; we need to build a company,’” Dr Griffin recalls. “We talked about how we wanted to be the company that doctors trust and recommend to their friends because orthodontics is a community we care about. I knew from there [that] I had the right partner. And then, we were chosen as Gold Winner at the 2016 annual MassChallenge Boston Awards, which really gave us some external validation that enabled us to take the next step.”

To launch the company, they needed more hands on deck. In a unique move, they formed an executive team made up of experienced professionals from a variety of fields, including manufacturing, technology, robotics, and consumer product development.

Dr Shuman remember the enormous impact Dr Griffin’s vision had on their company’s growth. “Alfred reached outside of dentistry and brought a level of expertise into the company like never seen before,” Dr Shuman says. “He came up with a concept that truly took orthodontics into the digital realm. No one else had ever been able to create 100% custom 3D-printed brackets.”

Before LightForce, orthodontics had lagged behind in terms of customization. Although clear aligners provided a certain level of personalized treatment, brackets still came in only 1 size, and it was up to the orthodontist to place and fine-tune them for each patient. Each stock bracket requires adjustment, repositioning, and wire bending, which can be time-consuming and takes up chair time. With LightForce’s 3D printing, customization is accomplished before brackets go into the mouth.

That way, the number of adjustments is reduced and so are the number of appointments. “If we can start with the ideal shape of that bracket and the ideal position, we don’t have to bend wires or reposition brackets, so we eliminate all those appointments for each case,” Dr Griffin says. “That means every tooth in the mouth takes essentially a direct flight to their ideal position as prescribed by the doctor, versus an indirect flight, which requires more tooth movement than is needed. Essentially, you’re starting with the end in mind.”

Before LightForce, “orthodontists just had one kind of bracket, where the base of the bracket doesn’t fit the tooth,” Dr Shuman says, but “with LightForce, the base of the bracket is literally customized to fit each tooth’s anatomy exactly. It really is a game changer.”

The digital nature of the process also allows for faster treatment. A mold can be modified just by changing an STL 3D-printing file, leading to many benefits, including decreasing turnaround time, accelerated tooth movement, and reduced chair and treatment time.

“With LightForce, you don’t need to monitor as closely,” Dr Shuman says. “You let the treatment plan work itself out. With stock brackets, you need to see that patient every 4 to 6 weeks because you’re not really sure what’s happening; you put the braces on by line of sight, but now you’ve got to react to it. You’re reactive. You can be proactive with LightForce. And so instead of every 4 to 6 weeks, you can see the patient every 8 to 10 weeks.”

Shorter treatment times are more convenient for patients and reduce patient burnout. If a patient has to be seen only 10 times instead of 17, that’s much less time that a parent needs to take off from work or that a child needs to miss school—a plus for everyone involved.

“The modern consumer values efficiency more than ever before,” Dr Griffin says. “Our early data suggests that we save roughly 8 months of treatment time, around 40% fewer months in treatment and 40% fewer visits. That’s substantial. And it’s because you’re starting with the ideal end results in mind.”

Many of the negative outcomes for patients with braces are closely correlated to treatment duration. The longer the treatment, the higher the risk of white spot lesions, cavities around brackets, and recession. Several studies have found that the risk of root resorption (which can lead to the tooth’s support being compromised, potentially to the point of tooth loss) increases with the length of treatment.

“If we can reduce those issues, then we’re going to get better outcomes,” Griffin states. “More and more people are getting braces than ever before; it’s growing at a 15% compounded annual growth rate. This means we need to continue to provide a higher standard of care for every patient.”

“The benefit is so much more far-reaching than just the technology shift,” Dr Shuman adds. “LightForce technology has a tremendous impact on how we treat patients and their treatment outcomes.”

Dr Shuman also notes that shorter treatment time means patients will return to the general practitioner’s (GP) office more quickly. “That has always been an issue,” he says. “After the GP refers to the orthodontist, the GP is left wondering when they will see that patient again. So, by the efficiency of the LightForce technology, we’re able to get that patient back to the GP quicker.”

A positive experience with the orthodontist also reflects well on the referring dentist. If the patients have an ideal and timely outcome, they will appreciate that the dentist referred them to that technology-savvy orthodontist.

“Contemporary dental professionals now are thinking [about] what the modern patient wants out of their experience,” Dr Griffin says. “People are redesigning offices and workflows around the modern consumer, and we’re thinking about that as well. I want to start my patients off in a place where I know their treatment is going to be successful.”

Although LightForce technology has only been available for 2 years, already more than 8% of North American orthodontists are using it—and with good results.

“We are quantifying the outcomes now,” Dr Griffin says. “What we’re seeing qualitatively is that doctors are reporting better outcomes with LightForce, and we expect quantitative data shortly.”

The impact of this technology has already become apparent to the industry, and the American Association of Orthodontics (AAO) chose Dr Griffin as the 2022 Ortho Innovator of the Year.

“The AAO is looking to the future and recognizing that LightForce is really moving the needle for the whole profession,” Dr Shuman points out. “LightForce is pushing technology to a level that will have implications far outside just orthodontics.”

Dr Griffin believes this forward-thinking industry is excited about the future. According to him, it is dentistry that is advancing the 3D-printing industry, largely due to its being the biggest user of 3D-printing technology. In fact, the largest 3D-printing company today is Align Technologies.

“We are pushing technology forward,” he says. “3D printing in dentistry shows that we value customization more than any other field of medicine or industry. I think in the future, everything that goes into the mouth should be customized because there’s a clinical benefit to both the doctor and the patient. And 3D printing and digital innovation are enabling this.” 

Krishnan V. Critical issues concerning root resorption: a contemporary review. 

Articles

3D printing and CAD technology have enabled LightForce to customize brackets in the same way that clear aligners are printed to fit each patient. 

Customized Brackets for Patients With Braces

Artificial intelligence (AI) is no longer a new concept in dentistry. It has been seamlessly integrated into numerous functions in dental practices, including practice management software, telehealth capabilities, image-guided oral and maxillofacial surgery, marketing campaign management, and now, perhaps most importantly, diagnostics and clinical decision-making.

“It’s clear that AI in dentistry, in every facet of running a dental practice and in health care, is going to continue to grow,” Albert Kim, CEO of SOTA Cloud, says. “The hope is it will continue to have a huge impact ultimately in patient outcome. Over the past 20 years, we’ve gone through a digital revolution in dentistry, and AI will compound that growth even faster and have a greater impact. With AI and cloud-based technology, we are in the early stages of unlocking the true potential of the digital revolution in dentistry.”

When it comes to diagnostics, AI can be effectively implemented in dental radiographs using neural networks.

 For instance, conventional neural networks (CNNs) quickly and precisely analyze images. This AI can detect tooth decay, restorations, periapical lesions, root fractures, and other anomalies in a fraction of the time it would take a human to do so—and oftentimes, more accurately.

A second type of neural networks are artificial neural networks (ANNs), which are programmed to detect patterns within data sets. This AI can be utilized to map anatomy of teeth or perform facial recognition. With both variations of AI, large amounts of data are fed into the systems so the technology can “learn” to identify these patterns and anomalies, growing more accurate as it is fed increasing amounts of data—data that would take humans extensive amounts of time to sort through.

“The power of AI comes from its ability to analyze vast amounts of data, identify patterns and trends, and automate tasks that used to be time-consuming for humans,” says Teresa A. Dolan, DDS, MPH, chief dental officer of Overjet. “AI is already becoming mainstream, and I predict most dental practices will adopt AI technology [once] they understand the benefit it brings to patient care.”

And the benefits are impressive, primarily stemming from the accuracy, reliability, and efficiency of the technology. A 2018 study examined the efficacy of CNNs at identifying dental caries on periapical radiographs. The results showed that CNNs had detection accuracy rates of 89% for premolars and 88% for molars.

 Even more impressive results came from a 2020 study that found that AI could identify caries with a 97.1% accuracy rate.

Results from the second 2020 study determined that AI successfully detected 97.6% of dental restorations on x-rays, leaving no doubt that the technology is effective.

“There’s a real human factor when it comes to a profession like dentistry because there’s a lot that can go on,” Kim says. “Even in a single periapical or bitewing x-ray, it is like the equivalent of 

This, Kim says, is why there are so many missed potential treatments and cases. There are constantly numerous things happening at once and the dentist is beholden to an x-ray image that may not be up to par for the full diagnosis. “There’s a lot that can be missed with many tools up to this point in the history of dentistry, especially when the dentist doesn’t have the luxury of time [and has so] many patients to care for,” Kim explains. “With today’s AI technology, the dentist can have the best tools available to make the best diagnostic inference. We’re now seeing—and building—the utilities to help dentists give better care than ever before.”

To evaluate accuracy among human practitioners in comparison with AI, a recent study by Pearl had dentists and a computer vision/learning machine (CV/ML) examine a sample of 10,000 radiographs to identify caries.

 The study had the humans and AI score the x-rays for the absence or presence of caries. It examined whether the participants agreed or disagreed and how that compared with the AI results. Researchers found that 3 clinicians unanimously agreed on the presence of caries or decay only 4.2% of the time and that the AI was better at determining the existence of caries on the x-rays than the human evaluators.

“Computers are just better than us at many things, like math or crunching numbers,” Ophir Tanz, founder and CEO of Pearl, says. “But they’re worse at issuing care and having empathy and being able to take lots of disparate data sets and come up with a treatment plan, etc. I think that we should be embracing the technology to support us in things that it is uniquely positioned to enable us to do better.”

Dr Dolan agrees about the advantages of AI in regards to data analysis and consistency.

“AI helps overcome one of the biggest challenges in dentistry: inconsistency,” she says. “Dentists’ training, experience level, philosophy, and even fatigue can influence their diagnosis. Artificial intelligence is objective.”

This objectivity can be a valuable tool in the clinician’s arsenal and a powerful diagnostic tool to complement a dentist’s capabilities and assessments. However, professionals say, it is in no way designed to replace the dentist.

“Machine learning and AI-powered applications provide dentists an objective view when faced with a difficult diagnosis,” says Lea Al Matny, DDS, MS, a clinical education specialist at Carestream Dental and an oral maxillofacial radiologist with SeeThru Reports. “This in no way undermines expertise, training, or the skilled diagnostic integrity dentists bring to analyzing x-rays and providing patient care. But it augments the capability, accuracy, and the precision of the diagnosis and treatment.”

Ultimately, it can never hurt to have a second set of eyes, particularly for a busy dentist trying to juggle all aspects of the practice without sacrificing patient care.

“No dental school is sending practitioners in the field proficient enough at identifying pathology,” Tanz says. “Dentists are expected to learn out on the job, and maybe you get pretty good at it, but you’re still missing a bunch of stuff. What AI is doing is surfacing a new level of truth. As a result of AI, you’re getting better, more comprehensive, more accurate, and more precise detection of pathology. You can refer back to the clinical trials and see computers are able to identify pathology in a way that is superior to humans. AI eliminates that variability and ultimately we can unburden practitioners and allow them to focus on things that matter.”

Tanz sees AI as such a supporting tool that Pearl named its AI platform Second Opinion®. Second Opinion uses generative adversarial network (GAN) preprocessors to enhance x-rays when the images aren’t top quality. Image preprocessors and machine-vision models combine to detect restorative, pathologic, and anatomical features on images. The software segments teeth to assess the anatomical structures and identify various pathologies, including caries and calculus, restorations, margin discrepancies, lesions, and periapical radiolucency. Pearl has FDA clearance to evaluate for these conditions in both bitewing and periapical x-rays in patients as young as 12 years. Beyond the United States, various international regulatory boards have cleared Pearl for market in more than 90 countries.

“AI enables us to drive the highest standard of care,” Tanz says. “We’re just delivering a level of truth that is totally transparent, that is totally verifiable. But [it] is also provably statistically quite good. And we should be embracing truth above all else because that is what’s going to lead to healthier patients.”

“AI-powered applications will make dental care more efficient by freeing up the dental team from mundane tasks,” Dr Al Matny says. “The focus will also be on improving accessibility of health care for a wider population at a more affordable cost, eventually leading to preventive dentistry.

The dedication to better patient care extends across the industry—after all, AI is only as good as the benefits it brings to patients. One way to increase these benefits is to make AI more efficient and accessible. To achieve this, several industry partners are teaming up.

Cloud-based dental software company Planet DDS and dental-AI company Overjet recently announced a partnership to incorporate AI capabilities into Planet DDS’ Apteryx XVWeb Cloud Imaging software and its Denticon practice-management platform. This integration will allow clinicians to improve diagnostic accuracy with Overjet’s AI from any imaging device, thanks to the scalability of the Apteryx XVWeb software.

“Cloud and AI technologies are transforming the practice of dentistry,” Eric Giesecke, CEO of Planet DDS, said in a news release announcing the partnership.

 “With this integration, dentists can harness the power of both technologies to give patients more transparency and confidence in diagnosis and treatment planning.”

This partnership is an added bonus to Overjet’s already-robust capabilities. Overjet is the only AI provider with FDA 510(k) clearance for bone level quantification (including measuring distal and mesial alveolar bone levels in bitewing and periapical radiograph), and its software gives clinicians simple quantification when measuring bone levels, eliminating the need to visually estimate the measurement from the cementoenamel junction to the crestal bone to determine if there is bone loss.

“Having the AI-powered quantification not only helps providers, but also can provide the radiographic evidence of bone loss that most dental payers require in adjudicating periodontal treatment claims,” Dr Dolan says. “Dentists have the information needed to help diagnose both restorative and periodontal treatment needs.”

To gather the information necessary to support this AI, Overjet’s machine-learning algorithms have processed more than 28 million images from dental practice clients. Fifty licensed dentists annotate images from these clients to continually train, test, and validate the AI models. According to an internal study, Overjet analyzed more than 7000 tooth surfaces and found that when dentists used the AI, they were able to detect 32% more tooth surfaces containing caries.

“Dentists want to provide the best care possible to patients,” Dr Dolan says. “Just as they may call over a clinical colleague to take a look at an x-ray and confirm what they see, they can depend on Overjet’s AI to provide an objective analysis. It draws the eye to potential areas of concern, which the dentist can then review and diagnose. AI elevates the dentist’s ability to diagnose accurately and consistently; it doesn’t replace it.”

The company doesn’t plan to stop developing and growing any time soon. The easy-to-use platform offers real-time AI analysis, and clinical and operational insights, and integrates with the digital imaging and practice management systems to draw data from prior visits to help identify potential treatment needs. This, Dr Dolan says, is just the beginning.

“Overjet is developing more AI models to detect pathologies in permanent and primary dentition,” she says. “It’s also exploring point-of-care adjudication with insurance carriers, which would eliminate one of the biggest concerns patients have: wondering if insurance will cover treatment. It’s working with universities to introduce dental students and residents to AI-assisted dentistry. And it’s evaluating ways to integrate dental and medical records to use predictive analytics to promote personalized health care recommendations that will improve patient outcomes.”

Overjet isn’t the only one committed to improving patient outcomes through collaboration. Pearl’s Second Opinion can now be easily accessed through SOTA Cloud software.

“With our SOTA Cloud software—built with years of insight into dentists’ workflow structure—we created a platform where AI can be seamlessly used within their current workflow, which makes it easy to add into their processes,” Kim says. “With our new update, users can simply click on a button in our SOTA Cloud software to access Pearl’s AI tool Second Opinion, so it doesn’t take any additional training or windows that need to be managed. Using AI just becomes second nature, like taking an x-ray and adding a filter. With SOTA Cloud, we are decluttering the workspace to help dentists optimize workflow and utilize AI at higher rates.”

To utilize AI effectively, Kim says, it all starts from the ground up by taking the x-ray and getting the raw data. That’s what feeds into the imaging software, such as Pearl’s AI.

“We are starting from the source of that data by applying our own AI in the form of enhancing the image so that it’s optimized so that when it goes into AI diagnostics, they’re putting in good high-quality data,” he says. “We’re embedding AI into our products so this new technology has the best workflow for adoption. We also put AI into our hardware (x-ray sensors) so we create the most optimized data, not only to enhance doctors’ visual diagnostics but to help other AI technologies like Pearl by feeding it good data.”

This integration is key for streamlining workflows. To do this, companies such as Carestream Dental are integrating AI diagnostic tools directly into their imaging software and clinical evaluation workflows. Once the image is acquired and displayed, an AI reading is available with a single click. The AI software automatically detects a broad range of pathological and nonpathological conditions on the x-rays and highlights findings in color, both on the image and on the interactive chart. Findings are automatically documented into a comprehensive report, which includes the x-ray image, a dental chart, and the list of findings, saved into the patient file. Carestream also has integrated AI into its CS 9600 CBCT system, which uses AI-powered positioning to ensure consistent results.

“AI applications can be used to reinforce confidence and increase consistency by using a real-time second opinion,” Dr Al Matny says. “The focus should be on increasing consistency, and as a result, improving patient health.”

An important step to improving patient health is securing patient treatment acceptance, which can be an onerous task. Patients may not understand why they need treatment or what markers are showing up in their current oral-health status that could develop into bigger issues down the road. One benefit of AI is its opportunity for patient education.

“Most patients don’t know how to read traditional x-rays, but when they see the AI markings that outline decay and measure bone loss, there’s an ‘A-ha!’ moment,” Dr Dolan explains. “Seeing the objective findings builds trust and confidence in their doctor’s diagnosis and treatment recommendations. Dentists and dental organizations have been enthusiastic about integrating AI technology into their practices, especially after seeing the value it brings to patient care and practice efficiency.”

Results of a 2022 study found that when patients were shown a radiograph with an arrow pointing to a lesion, they were much less likely to be able to see or understand it than when using AI-generated colored overlays highlighting the issue.

 Patients responded well to the AI-supported diagnostics and radiographic findings, thanks to the easily understandable visual explanation of the pathologies.

“Overjet’s AI instantly analyzes x-rays and applies color and measurements to draw the eye and help with clinical decision-making,” Dr Dolan says. “This AI does more than just help dentists diagnose accurately; it also gives them a powerful tool for patient education and communication.”

For all the benefits AI is bringing to diagnostics, there are many more coming down the road. Neural networks and AI are already excelling at detecting tooth decay, assisting with root canal system anatomy, performing cephalometric points marking in orthodontics, and more. To take AI to the next level however, dentists need to embrace what’s already there.

“There’s always a fear of adopting new technology because we are inherently not creatures that adopt change. Especially with something nascent like AI, it can be scary for a lot of doctors at first,” Kim says. “The less they know about it, the more they see AI as something to fear. But I think it’s important for them to understand this is really a technology that aids the process of the dentist who is ultimately the professional, [with] the dentist knowing they have the ultimate say and ultimate executive decision-making power, and that AI is just an aid.

“AI is just at the forefront, in its infancy,” Kim continues. “It’s going to require even more diligent surveillance of how this is affecting users and how this is ultimately bettering clinical care for the dental practice.”

Dr Dolan agrees that the industry is on the brink of something great. “We are just getting started,” she says. “AI gives dentists a powerful tool to help diagnose accurately and consistently, and we’re proud to lead the movement to make dental care more patient-focused.”

Ultimately, the consensus is that tools such as AI are only going to become more valuable over time, enabling dentists to provide better care and allowing them to focus more on the bigger picture.

“Dentists do a lot, and I think to the extent that we can unburden them so that they can more effectively issue care and do that in a way that that has benefits to patients, that’s what’s going to enable them to be better practitioners,” Tanz concludes. “And that’s a no-brainer.”

Ossowska A, Kusiak A, Świetlik D. Artificial intelligence in dentistry—narrative review. 

Lee JH, Kim DH, Jeong SN, Choi SH. Detection and diagnosis of dental caries using a deep learning-based convolutional neural network algorithm. 

Geetha V, Aprameya KS, Hinduja DM. Dental caries diagnosis in digital radiographs using back-propagation neural network. 

Abdalla-Aslan R, Yeshua T, Kabla D, Leichter I, Nadler C. An artificial intelligence system using machine-learning for automatic detection and classification of dental restorations in panoramic radiography. 

Oral Surg Oral Med Oral Pathol Oral Radiol. 

Carter C, Sant N, Annigeri R, Puttaschamachar N, Stanley K. Can a computer identify carious lesions in dental x-rays as accurately as humans? Pearl. Accessed December 27, 2022. 

https://f.hubspotusercontent10.net/hubfs/5664760/Pearl-Second%20Opinion%20Study-Caries%20Whitepaper.pdf

Planet DDS partners with Overjet to usher in new era of AI-powered dental imaging. News release. Businesswire. December 8, 2022. Accessed January 13, 2023. 

https://www.businesswire.com/news/home/20221208005341/en/Planet-DDS-Partners-with-Overjet-to-Usher-in-New-Era-of-AI-Powered-Dental-Imaging

Kosan E, Krois J, Wingenfeld K, Deuter CE, Gaudin R, Schwendicke F. Patients’ perspectives on artificial intelligence in dentistry: a controlled study. 

AI-powered diagnostic systems can improve the effectiveness of identifying caries on radiographs.

How AI is Changing the Face of Diagnostics 

When Alfred Fones graduated from dental school in 1890, his primary role as a dentist was pulling already-rotten teeth. Pediatric patients were coming into their first-ever appointments and were already presenting with decay. Clearly, something needed to change.

Perhaps, Fones thought, the answer would be preventing the problems before they start. From this concept, he recruited his cousin, Irene Newman, to become what would come to be known as the first dental hygienist.

“Dental hygienists were conceptualized and created out of a perceived need within the community at that time for somebody who would be able to increase access to care,” says Katrina Sanders RDH, BSDH, M.Ed, RF. “Fones thought to himself, ‘We need to create some sort of a position, an advocate, someone who can go out into the community and increase awareness and improve oral health as a community advocate before these individuals even come into a private practice setting.’”

Thus began the dental hygienists’ immense impact on preventative oral health care and expanded oral care access. Newman and her colleagues trained patients in good oral hygiene habits, dietary choices, the importance of toothbrushing, and more, to better both their oral and overall health—so successfully, in fact, that 5 years after Dr Fones and Newman founded the first dental hygiene school in Bridgeport, Connecticut in 1913, the city had the lowest death rate of any large city in the world during the 1918 flu.

Over 100 years later, dental hygienists continue to make a huge impact on oral health care.

“Given that virtually all dental disease can be prevented, that puts the dental hygienist in a really integral and critical part of the dental delivery team,” says Ann Lynch, director of advocacy for the American Dental Hygienists’ Association (ADHA). “Dental hygienists are right at the front line as the prevention experts.”

Fones’ and Newman’s first dental hygiene program opened the door for hygiene education, and their legacy lives on: Since the University of Bridgeport established the first dental hygiene college, the Fones School of Dental Hygiene, in 1949, there are over 320 entry-level hygiene programs and 17 master’s degree programs in the United States.

The continuing increase in dental-hygiene programs also means an increase in care access, including a growth in direct access care. According to the ADHA, direct access is “the ability of a dental hygienist to initiate treatment based on their assessment of a patient's needs without the specific authorization of a dentist, treat the patient without the presence of a dentist, and maintain a provider-patient relationship.”

 In 2008, 28 states allowed direct access. In 2021, that number was up to 42.

“Today there are 42 states that are direct access states,” Lynch says. “That means that in at least 1 setting and often, in several settings, dental hygienists can see the patient and provide services without the authorization or physical presence of a dentist. That's been really important to increasing access to care and frankly, getting care to where people are, such as school-based programs or geriatric patients that are in skilled nursing facilities.”

Increased direct access greatly benefits underserved communities by giving them access to oral health care and education tools for prevention without the need for dentist oversight. Offsite care allows hygienists to bring dental care to communities instead of requiring the patient to come to them, while teledentistry has opened doors even further.

“There are ways dental hygienists have increased access to care even through doing humanitarian work, helping to serve and support underserved areas, such as going into remote community areas and delivering care to those areas of senior living facilities or special care clinics being educators,” Sanders says. “And certainly, it has been very interesting to see how technology has helped to leverage what dental hygienists are able to do in that telehealth and telemedicine space.”

However, there’s still room for growth, as each state currently has its own restrictions and regulations about a hygienist’s scope of practice. While dental hygiene schools are all accredited by the Commission on Dental Accreditation (CODA), what hygienists are authorized to do with that education varies from state to state.

“I think is possible is there are some states where dental hygienists are not permitted to practice to the fullest extent of their education because of the scope of practice,” Lynch says. “There are national accreditation standards for dental hygiene education programs, so no matter which state you attend a dental hygiene program in, everyone has the same educational accreditation standards. However, depending on the scope of practice, they may or may not be permitted to provide all of the services for which they are educated and trained.”

And these limits on scope can influence access to care. A 2016 study from the SUNY University at Albany’s Center for Health Workforce Studies found that oral health notably improves in states where hygienists are allowed to practice at higher levels and that, despite recent progress in improving access to oral health services, underserved populations continue to suffer from lack of delivery of clinical and community preventive services.

“The scope of practice for dental hygienists is different in every state,” Lynch says. “In the states where there isn’t direct access, they could adopt legislation to remove those frankly archaic barriers and permit dental hygienists to practice to the extent of their education. We are seeing that dental hygienists being able to practice without the physical presence of a dentist, has helped to increase oral health care access, as we've seen in schools, Head Start programs, skilled nursing facilities, and even hospitals in some cases.”

Despite holdups in some states, the overall trend is heartening. In 2018, the US Department of Labor’s (DOL) Bureau of Labor Statistics recategorized hygienists as “Healthcare Diagnosis or Treating Practitioners” from “Health Technologists and Technicians.”

 This reclassification could open doors for more opportunities for hygienists nationwide and expand the scope of practice to allow for even more comprehensive direct-access care.

Direct access isn’t the only frontline service increasing access to care. Dental therapy licensure has also provided greater opportunities for populations to receive preventive care, as well as, in some states, nonsurgical extractions, and preparation of teeth for direct restorations.

Because of its benefits to underserved populations, dental therapy has seen growing support from even the federal level. A 2018 report from the U.S. Departments of Health and Human Services (HHS), in conjunction with the Department of Treasury and DOL, released policy recommendations to improve competition and choice in healthcare markets. The report suggested states assess emerging healthcare occupations, including dental therapy, and examine how licensure scope of practice can increase access and decrease consumer costs while ensuring safe care.

Currently, Arizona, Connecticut, Maine, Michigan, Minnesota, Nevada, New Mexico, and Vermont, as well as tribal lands in Alaska, Idaho, Montana, Oregon, and Washington, have embraced dental therapy as a viable model for addressing access to care challenges.7 As of April 2021, nine more states (Florida, Indiana, Kansas, Massachusetts, New Jersey, New York, Oregon, Washington, and Wisconsin are pursuing dental therapy licensures.

 The ADHA reaffirmed its commitment to dental therapy in advocating support of new hygiene-based models for oral health care in a statement released by the organization in 2021.

One way the ADHA accomplishes this is by providing continuing education opportunities for hygienists to increase knowledge bases—as it has now been doing for a century. In July 2023, the ADHA will celebrate its 100th anniversary at its annual conference in Chicago from July 7-9.

“The conference is a terrific opportunity for the dental industry to support dental hygienists,” Lynch says. “The dental industry continues to provide new technology and evidence-based research and it really can be a resource for all members of the dental delivery team.”

Another opportunity for dental hygienists to magnify their education is to explore expanded function dental auxiliary programs (EFDAs). EFDA certification allows dental health care professionals, such as hygienists, to perform reversible dental procedures under the direct supervision of the dentist. While about half of US states allow some EFDA duties, as with seemingly all hygiene regulations, the permitted procedures—and the education requirements to perform them—vary wildly from state to state.

Since its development in the 1970s, EFDA certifications have allowed hygienists in some states to perform the placement and carving of amalgam restorations; placement contouring, and finishing of composite restorations; fabrication, cementation, and removal of temporary restorations; and more. While all of this must be performed under a dentist’s direct supervision, it allows for an expansion of efficiency within a practice, allowing more patients to be treated and thus increasing access to care.

While access to care is critical, getting patients into the chair in the first place is another monumental challenge to providing care. A 2019 National Center for Health Statistics survey found that nearly 45% of adults aged 18-64 had not had a dental visit in the past 12 months, and in rural areas, that number grew to almost 63%.

Sanders sees unique opportunities for dental hygienists to reach this population and educate them about the importance of oral health. From social media, YouTube channels and news appearances, to hygienists going into schools or sending letters to parents to educate them, hygienists can have a large impact on their communities.

“Dental hygienists sometimes don't realize the influence they have even on the patients that do not come in to see them,” she says. “Even on social media; you have a large body of individuals—who are not dental professionals—who see hygienists’ posts or the articles they’re cross-posting. And that starts to create a very organic way for the community to metabolize our content. And now we have the opportunity to really leverage a conversation where people, not even the people in our chairs, but the other people who are interacting with our thought leadership pieces or articles—these individuals are also beginning to understand the importance of oral health.”

Because dental hygienists are often the patient-centric faces of oral health care, Sanders says, they have a unique opportunity to serve as conduits to more than just good oral health. Hygienists talk to patients about decay, gingivitis, periodontitis, oral cancer—and even health conditions outside of the mouth. For example, if a hygienist takes vital signs, they can advise a patient about high blood pressure or pulse rates, and suggest they see their primary care physician.

“Dental hygienists being trained and coached in these things really helps to position them to be true preventive specialists,” Sanders says. “Not that we're looking for disease, but that we are actually looking for those risk factors that could lead us to disease, and ultimately be able to support our patients in that right. The current statistics indicate about 27 million Americans will see a dentist this year, but not see a primary care physician. Dental hygienists can be not just the preventive specialists in dentistry, but also true preventive specialists in the healthcare space.”

Sanders feels the COVID-19 pandemic opened doors to more conversations about oral-systemic health; many of which put hygienists on the front line.

“Our patients absolutely saw us positioned to be able to support in a lot of those ways during a pandemic, when they would say, ‘I'm 65 years old, I'm a diabetic, I have a respiratory condition; I'm scared that by coming to see you that I could get COVID.’ And for a dental hygienist, that was an opportunity to partner with a patient and both reassure and educate. You could say, ‘I hear you, and I’m just concerned as you are. But let’s talk about risk factors.’”

This, Sanders says, opened the door to a lot of important discussions.

“Let's talk about why inflammation in your mouth actually becomes a far more concerning risk factor for you and how we can do everything we need to do to ensure that we're protecting you,” she says. “Let's talk about the infection-control steps that we take in our practice. Let's talk about the aerosol mitigation strategies that we've employed. That allows dental hygienists to position themselves as true patient advocates to form a patient-centric, personalized care plan before the patient even sat down in our chair.”

Spurring conversations like these, the pandemic shined a light on the link between oral and bodily health—and many people started to understand that they are not mutually exclusive. More and more people began to notice, understand, and embrace the concept of oral-systemic health, due in part to education from people like dental hygienists.

“It has long been that medicine and oral health been viewed as being not connected,” Lynch says. “Now we know with a growing body of research how [oral health] is connected to the body, and if you don't have a healthy mouth, you don't have good overall health. There has been increasing interest and increasing growth in medical-dental integration—and that's a really good thing.”

Ultimately, hygienists are situated uniquely in their ability to reach patients and broaden access to care, with ever-increasing opportunities to do so.

“It’s incredible now, over 100 years after the advent of dental hygiene, as we look over the balcony at where dental hygienists are today, that there are so many ways in which dental hygienists have been able to step into roles to be able to increase that access,” Sanders says. “Whether that is through delivering direct care, like in mobile dental clinics; through telehealth or telemedicine; through patient counseling; or even working with various technologies like salivary diagnostics that allows dental hygienists to look at the oral DNA of the patient and counsel them on appropriate predicaments, etc. It's really amazing to look at the level of influence hygienists have in providing access to care. And it’s only going to continue.”

Lehman ED. Alfred Fones, Irene Newman, and the dental hygiene revolution. Bridgeport History Center. Accessed December 8, 2022. 

https://bportlibrary.org/hc/education/dr-alfred-fones/

Dental hygiene by the numbers. American Dental Education Association. Accessed December 8, 2022. 

https://www.adea.org/GoDental/Future_Dental_Hygienists/Dental_hygiene_by_the_numbers.aspx.

Advocacy: Direct access. American Dental Hygienists’ Association. Accessed December 8, 2022. 

Langelier M, Continelli T, Moore J, Baker B, Surdu S. Expanded scopes of practice for dental hygienists associated with improved oral health outcomes for adults. 

. 2016;35(12):2207-2215. Accessed December 8, 2022. 

https://doi.org/10.1377/hlthaff.2016.0807

2018 Standard occupational classification system. United States Department of Labor Bureau of Labor Statistics. Published November 2017. Accessed December 8, 2022. https://www.bls.gov/soc/2018/major_groups.htm

Reforming America’s healthcare system through choice and competition. https://www.hhs.gov/sites/default/files/Reforming-Americas-Healthcare-System-Through-Choice-and-Competition.pdf. Published 2018. Accessed December 8, 2022. doi.org/10.1377/hlthaff.2016.0807

Expanding access to care through dental therapy. American Dental Hygienists’ Association. Published April 2021. Accessed December 8, 2022. 

Cha AE, Cohen RA. Urban-rural differences in dental care use among adults aged 18−64. National Center for Health Statistics. Published July 7, 2021. Accessed December 8, 2022. 

https://www.cdc.gov/nchs/data/databriefs/db412-H.pdf

Over 100 years after the field was created, dental hygienists remain on the front lines of disease prevention as they create more direct access opportunities for patients. 



Hygiene's Role in Expanding Oral Care Access

The Proactive Approach: Salivary Testing for Preventive Care


Over the years, dentistry has taken a reactive rather than proactive approach to oral health. Much of its emphasis has been on fixing problems once they’ve taken root. This narrow focus leads to the continuation of the same set of problems. In his pediatric practice in North Ogden, Utah, Boyd Simkins, DDS, used to feel as if he were facing a revolving door of caries.

“I got tired of just filling cavities,” he says. “I got to the point where I was unfulfilled because I was just doing the same thing, day in and day out. I wanted to break this endless cycle.”

To achieve his goal, Dr Simkins began exploring salivary testing for use as a preventive tool that would change how he—and the dental industry—approached assessment, prevention, and treatment.

“If we really want to be a profession that focuses on prevention, we can’t wait until the disease is manifesting,” Dr Simkins says. “If we can proactively see what is happening, we can reduce the risk for decay or disease in general, then we can really create a movement…not only [for] our profession but…[for] medical colleagues as well, to shift the paradigm in Western medicine.”

The SillHa Oral Wellness System is a salivary screening tool that allows dental professionals to test patient saliva in just 5 minutes, allowing for a quick analysis to bolster preventive care and treatment planning. It uses a dual reflectance method to measure reactivity to saliva, providing tested results and checking for inflammatory markers. The report offers easy-to-understand data visualization to help clinicians make informed decisions on patient care.

Salivary testing is certainly a proactive approach that identifies risk factors for caries and periodontal disease before the problems arise. Although it offers benefits for both children and adults, as a pediatric practitioner Dr Simkins found it extremely useful for his young patients.

“With kids particularly, we can shape the microbiome before it’s established,” he says. “We can use the saliva before things start showing up on radiographs or in the clinical exam. We can see that there’s risk, so we can actually preemptively start to make changes, whether it’s to diet or probiotics or specific types of toothpaste or habits in general, and try to prevent that disease from showing up.”

As he began focusing on salivary testing, Dr Simkins tried a number of the systems available. Some had multiday turnaround times, which wasn’t conducive to patient education or convenient for his practice workflow. He felt that it wasn’t practical to call numerous patients a few days after their appointment to discuss results. Other systems didn’t seem to produce reliable results or lacked the ability to track progress over time. In 2019, he discovered the solution he currently employs.

“We tried a few different salivary testing products, but we found they either took too much time or weren’t very predictable,” Dr Simkins explains. “Then we found the SillHa Oral Wellness System, which is approved for use with both children and adults.”

And he was on the right track. A 2022 study examining the benefits of this product from ARKRAY USA, Inc, found that the multipoint saliva analyzer, in conjunction with clinical examination, can provide quick salivary component analysis to support effective treatment planning.

By using SillHa to test saliva, one can assess a patient’s risk for caries and periodontal disease. In just 5 minutes, it analyzes saliva samples for 7 key biomarkers of oral wellness: ammonia, acidity, proteins, buffer capacity, leukocytes, blood, and cariogenic bacteria, which can indicate predisposition to a range of conditions. For example, the research found that higher leukocyte and protein levels were found in patients with periodontal disease, whereas acidity levels were lower in patients with sleep apnea. Those with a history of cancer or diabetes had lower leukocyte but higher ammonia levels.

Although SillHa offers extensive in-depth results, it is quite simple to use. After a practitioner submits a saliva sample to the system, it is examined using a dual reflectance method, which measures the saliva’s reactivity on a test strip. This reactivity provides information on factors invisible to the naked eye that may point to an increased risk of disease or caries.

Once the sample has been analyzed, the system produces a patient-friendly, multipoint analysis of the results in an easy-to-understand format. The mySaliva⎫

 report provides information on current oral status, outlines benchmarks for improvement, and specifies the reasoning behind follow-up appointments.

The report is formatted in either a radar or bar chart that displays information graphically so that patients can readily understand it. Each report includes the 7 biomarkers and allows the clinician to determine the risk for disease combining the numbers with knowledge and clinical assessment.

For example, a patient with high acidity levels can see that a diet that includes acid-producing foods can be a possible cause. The report also explains the effects high acidity can have on teeth and offers recommendations for reducing it, such as limiting simple/processed carbohydrates, practicing proper oral hygiene, or using specific over-the-counter products. Doctors can customize the causes and explanations about recommendations to fit their preferred suggested treatment plans. The system also allows them to compare up to 3 results over time to track patient progress.

“SillHa graphically depicts trends that we’re seeing in the saliva,” Dr Simkins says. “Any time we do saliva testing, it’s a point in time. So, by creating where you can track results over time, you can see trending and progression towards oral health. And it gives us those concrete numbers that allow us to say, here is the problem and why.”

Dr Simkins has found both the tracking feature and the visual biomarker depiction charts to be exceedingly helpful when explaining potential issues and suggesting care.

“I think the biggest thing I noticed when we started to test was that the parents started to pay attention about preventive care,” he says. “They actually started to listen to what I was saying, because we could put an objective piece in front of them that really showed exactly what was going on.”

Implementing Salivary Testing With SillHa

The ability to produce an accurate analyses in 5 minutes is particularly important to Dr Simkins, as his pediatric patients and their parents are often short on time because they’re running from school to sports practice and other events. The 5-minute turnaround time allows him and his team to discuss the findings and their implications at the end of the appointment. Hygienists can kick it off before the cleaning and exam, and results will be ready by the time the doctor is done.

“My patients and their families are so busy, they don’t have time to discuss results later, or it’s harder to get them to follow through if they aren’t in front of you,” Dr Simkins says. “SillHa is much easier than other systems and better for patient communication in that it only takes 5 minutes to get results.”

Setup is simple, and it is compatible with Windows and Apple software.

“Implementation was really easy,” Dr Simkins says. “The challenging part as the practitioner was figuring out how to interpret the data, and resources are provided to get there.”

Dr Simkins believes that any slight learning curve with SillHa is greatly outweighed by the insights and support that salivary testing can provide. Such testing has not only slowed down the revolving door of caries in his practice, but also allowed him to contribute to the betterment of his patients’ oral-systemic health.

“There are so many parts of overall health that science is showing [are] linked to oral health, everything from diabetes to cardiovascular disease,” he says. “If we can see all these things start to take root and make corrections early, especially in children, we’re going to see fewer complications.”

And dentistry is positioned to make a difference in combatting lifelong precursors to oral and systemic disease, provided it embraces preventive care and treatment.

“Our profession is in a really unique situation, where we are at the forefront of the health industry…[and] seeing people on a regular basis,” he says. “If you can harness the regularity of visits, we can start fighting disease and start collaborating to improve overall health.” 

Adibi SS, Hanson R, Fray DF, et al. Assessment of oral and overall health parameters using the SillHa Oral Wellness System. 

Oral Surg Oral Med Oral Pathol Oral Radiol.

 2022;133(6):663-674. doi:10.1016/j.oooo.2022.02.007

This new system allows practitioners to test patient saliva in just 5 minutes and catch issues before they become too serious. 

The Proactive Approach: Salivary Testing for Preventive Care

The Inexorability of Artificial Intelligence: Where, Why, and How AI Is Being Embraced By the Dental Industry. Image courtesy of putilov_denis/stock.adobe.com. 


Every practice wants to streamline processes, be it in the operatory or the front office. Over the past few decades, the advent of digital imaging and electronic health records has pushed the industry forward in terms of optimizing workflows. But the progress doesn’t stop there. The integration of artificial intelligence (AI) into the dental practice workflow is making current digital technology look like old news, and the implications for the future are staggering.

“I am really genuinely excited about what is happening in AI and dentistry,” says Ophir Tanz, founder and CEO of Pearl. “Timing is…critical when you’re introducing a fundamentally new capability into a market, and I think that the timing is really perfect for the dental market. I think the adoption is absolutely already there and going to continue to accelerate. It’s our belief that within 5 to 7 years, this will really be a utility within dental practices on a global scale.”

AI in its popular forms—Alexa, Google, and Netflix interfaces—was integrated into our daily life and is now commonplace. Tanz believes that the dental industry isn’t far behind with some AI implementations. We are past the introductory period and moving into a period of adoption, just as we did with consumer-based AI technology.

“We’ve graduated from the very early adopter phase…and are really now at a point where there’s a lot more general awareness globally about the capability, and there’s a lot of interest in it,” Tanz says. “Today AI is this new kind of hot thing that’s highly visible. And that’s all very exciting, but ultimately, it will just become part of the plumbing and be fundamental to how you review radiography and communicate with patients.”

Industry opinion leaders agree that this “plumbing” will soon support all aspects of the dental practice, particularly as the technology continues to expand and to be applied in different areas.

“Currently, we’re seeing AI for caries detection as the breakthrough innovation in dental. However, we also anticipate other use cases, such as auto-charting,” says Eric Giesecke, chief executive officer of Planet DDS. “I believe the pandemic accelerated the development and adoption of new technology within dentistry. Whether you’re looking at the need for cloud-based practice management or imaging software to enable remote working arrangements, allowing…practices to expand their hiring pool geographically, or teledentistry, practices are finding ways to stay resilient through technology.”

Perhaps the most highly discussed AI implementations these days are clinical applications like caries identification and diagnostic support tools, which have taken the industry by storm. Such companies as Pearl, Overjet, and VideaHealth are implementing AI for pathology detection and using machine learning to more accurately evaluate radiography for problem areas with greater accuracy.

AI can do this because the software accumulates and stores immense amounts of data and experiential knowledge and creates a reference database that can solve future problems. In dental applications, the data include hundreds of thousands of images for AI to analyze and to learn to identify and differentiate. As more images are input into the system, it learns more and becomes more accurate.

And accurate it is. A 2020 study fed 105 digital radiographs into AI software to determine the accuracy with which it could identify caries and found that it had a 97.1% accuracy rate.

 A 2022 study challenged AI software to detect and label teeth and missing teeth in fully and partially dentate patients, and it did so with a 99% success rate for detection and a 99.7% rate for labeling.

 In a third study, when tasked to identify dental restorations on radiographs, AI algorithms successfully detected 94.6%.

“By helping highlight suspicious areas in the mouth, we can increase consistency among practitioners and improve diagnostic accuracy,” Giesecke says. “It’s a win-win for patients and dentists when you think about how AI can identify problem areas based on learning from a staggering number of dental images that no human could possibly analyze. AI’s most significant advantage over humans is its ability to learn patterns by analyzing data at an astonishing rate to continually become more effective at what it does.”

AI is becoming a mainstay in dentistry. Because its adoption has led to new workflows, dental professionals may want to keep an eye on it.