Lauren Krzyzostaniak

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Should your practice enter the world of EHR? You should consider these things before you take the plunge.

9 Questions to ask about EHR

	While electronic health records (EHRs) are widely used in medicine, it hasn’t quite taken off in dentistry. Some experts, like Mike Uretz, executive director of DentalSoftwareAdvisor.com and dental software advisor for Dental Products Report, tout the advantages and inevitability of EHRs in dentistry, while others aren’t quite so sure. Dr. Lorne Lavine, founder and president of Dental Technology Consultants, had once advocated for dental practices to invest in EHRs but is no longer a proponent. Now that the meaningful use incentive is no longer available, there’s just no real reason to invest, he says. 

	“When the funding was available and the office qualified [for the incentive], we absolutely advised [investing in an EHR], because that was a significant amount of money available to them,” Dr. Lavine says. “That opportunity is now gone, so we are not currently pushing EHR as an option. Most dental practices use maybe 5-10 percent of what their dental practice management software can do. They use it for patient information, scheduling, billing, treatment planning, charting and that’s kind of it. The things that you would normally get in a full-feature EHR module, the vast majority of offices don’t need or want.” 

	And for “most” offices, he’s talking probably 98 percent of them. 

	“I would say that, of the offices we’ve worked with, the number of those using an EHR module is between 1-2 percent,” Dr. Lavine says. 

Related reading: What dental professionals need to know about the EHR incentive payment program

Uretz disagrees with this assessment, mentioning that although having eligibility for the incentive was a nice perk for a small amount of eligible offices, there are many patient care, operational and workflow reasons to obtain EHR. “There are [also] five more years available for Meaningful Use subsidies for qualified offices,” Uretz says. “In fact, I’m helping a number of practices and groups get substantial year two Meaningful Use incentives [this year] and will continue to help them obtain funds through the end of the program in 2021.”

	Plus, one reason that some dental practices might not have pursued EHR in the past is because of their business model. In that case, Dr. Lavine believes the future could bring about a greater increase of EHR use in dentistry as the dominant model swings from private practice to DSOs. 

	And with the number of third-party systems that integrate with practice management software, electronic health records seem unnecessary, he says. “EHR is supposed to take a bunch of disconnected systems and have them work together, but in dental, we don’t see as much of that,” Dr. Lavine says. “It doesn’t have the traction in dental that it does in the medical field.” 

Trending article: Are DSOs really taking over?

	But perhaps that will change as the industry evolves. 

	“Each year, the systems get better and better,” Uretz says. “Over the last three years, more software vendors have recognized the importance and hopped on board. The growth of multi-location groups has really accelerated EHR development. With groups, there are more locations and more dentists, and it’s important to standardize the patient care and manage what’s going on clinically. So that’s pushing more vendors to look at electronic health records.” 

	So should your practice take the leap into the world of EHRs? To help you decide, here are nine questions you should ask when considering whether electronic health records are right for your practice. 	 

	1. “Should I get an EHR that works with my practice management software, or get one system that has both components?” 

	If you decide that an EHR is right for your practice, you’ll need to decide if you’re going to invest in a separate system that can interact with your current practice management system, or if you’re going to invest in a system that has both. 

	“The better way to do it is to get a vendor that has both in one system so that it’s not two different systems talking to each other, it’s actually tied in together,” Uretz says. “You want that information integrated into one piece of software in one database.” 

Trending article: Why practice management systems are crucial

	“Normally, it’s less trauma to get something that directly integrates with the practice management software,” Dr. Lavine says. “Most of the major players have an EHR module that’s designed to work with their [practice management] software. It typically costs a little more than going with a third party, but you don’t have to deal with any of the integration issues. If all else were equal, I would say go with something that’s provided by the practice management company, unless they just can’t provide the functionality that you’re looking for.” 

	Going with a third-party system may save costs up front, but it won’t make financial sense in the long run. 

	“The downside of investing in a separate EHR system that claims to communicate with your present practice management system is that you’ll likely be doing a lot of double entry and you might eventually lose integration,” Uretz says. “Though they might work together in the beginning, there can eventually be a change on one side that will create a disconnect between the two, and integration will stop working. Or a company might decide they want both sides of the business and won’t allow interfacing. Most of the time when I’ve seen a practice do it this way, this is the inevitable result.” 

	2. “Is the software intuitive enough for me to actually use it every day?” 

	Approaching EHR software requires the same considerations as any other software, says Uretz. 

	“Delve deeply into the technology,” he says. “Is the system scalable? In other words, is it built on old technology that will be outmoded in two years? How’s the security? Will it interface with web portals?” 

Trending article: How EHRs can improve your dental practice

	He advises having a technical person look into those specifications so they can ask those kinds of questions.

	“It’s important when you look at EHRs to not just look at what you see on the screen, but also the underlying technology,” he says. “How does it interface with other third-party clinical software, like imaging? Can it interface with imaging in the cloud? Can it interface with different devices?” 

	Uretz also advises making sure it will interface with other clinical procedures in the practice, like taking blood pressure. “More dental providers are taking vitals such as blood pressure,” he notes. “So the question is if the EHR system will automatically interface with data from devices such as blood pressure cuffs in other monitoring machines. Or for another example, in the case of oral surgeons, are there possible interfaces between anesthesia monitoring devices and the EHR?” 

Trending article: The benefits of EHR in group practice

	And finally, make sure that the system is ideal for both the practice management and clinical sides. “The clinical people and the practice management people both have to like it,” Uretz says. 

	“Ease of use is probably the most important thing,” Dr. Lavine says. “The fact is that any system that has something unique will be copied by everyone else within a matter of months. But being able to learn and use the software is critical. My recommendation for offices is to get demos and involve their staff with it. At the end of the day, if the program is not intuitive, it doesn’t make a difference what features it has because you’re never going to use those.” 

	3. “Does the system have structured data?”

	Electronic health records are about more than just creating a paperless practice: it’s about using patient data more effectively. 

	“In dentistry, we are getting to the point where we can input data into the computer and do something with it,” Uretz says. “When a dentist does an exam or procedure, they can take that information and put it into a database. It’s searchable, so you can pull up critical information at any point on patients and procedures for many uses, including clinical decision making. It’s called ‘structured data’-the ability to enter clinical information about patients in a structured format and save it to a database so it can be used later.” 

Trending article: How dental EHRs can streamline referral processes

	Structured data provides additional benefits to group practices as well. 

	“There are many ways for dentists to do exams and procedures, which could potentially be a problem when it comes to managing group practices,” Uretz says. “So a benefit is having the ability to standardize care throughout the group and locations. Especially for new doctors coming out of dental school and going into a group practice, it’s a great way to make sure everyone is on the same page. It helps create efficiency in patient care.” 

	4. “Will this system simplify accountable care?” 

	“If you talk to dental insurance companies, you’ll find out they are moving toward accountable care, which has already been embraced in medicine,” Uretz says. “The idea of adding diagnosis codes along with procedure codes is essential to an accountable care model and is on the near horizon in dentistry. As the sheer volume of codes grows, it will be virtually impossible to manage without the use of electronic health records.

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	On the other hand, Dr. Lavine doesn’t think accountable care necessitates EHRs. 

	“Most dentists are using e-claims already, where the software can check for the validity of the claim right away and determine whether support documentation is needed,” he says. 

	5. “What impact will the system have on clinical decision support?” 

	“Through informatics efforts, there is a growing amount of information regarding oral health best practices,” Uretz says. “Suggested ways of handling cases comes out of clinical evidence and research. An EHR can give you information based on research on how you might handle the problem.

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	"The benefit of that is that no dentist or hygienist can keep up with all of the research being done, so having a tool that can offer clinical decision-making support helps providers make intelligent decisions about their patients based on evidence and information in the database. Providers aren’t required to follow guidelines presented, but it is helpful to have evidence-based information at your fingertips while you are making decisions.” 

	6. “Will having an EHR make my practice more efficient?”

	It certainly can, if you utilize all it has to offer. From streamlining information entry, offering electronic prescriptions and patient images, and automating patient recall, EHRs have the tools to optimize your workflow. 

	“Because, in many cases, billing information is manually entered into the practice management system after the patient clinical encounter, it’s not a streamlined process and can be prone to errors,” Uretz says. “With EHRs, [practices] have the ability to enter this information at the point of care when the work is performed and thus electronically move through the claims process without any double entry. In many cases that allows practices to be paid faster and prevents mistakes.” 

More from Mike Uretz: State technology subsidies: Dentistry's best-kept secret

	Electronic prescriptions offer more than convenience, says Uretz. “When you have a patient in the chair and need to prescribe medicine, you can push a button and get the information you need: all the meds a patient has been prescribed, whether from a hospital, primary care physician, nursing home or other provider,” he says.

	“Instead of the patient having to remember all of their medications, you have that information at your fingertips. You also have access to the contraindications. So, for example, if you prescribe a pain med, you’ll see if there is a potential interaction with other medications they’re on or with their allergies, which is good for patient care and especially helpful from a liability perspective. You’ll also see how they might tie in to dental conditions. It might say that certain drugs you are prescribing might cause dry mouth, for instance. And some systems allow you to see real-time formulary insurance coverage, so you know if you should prescribe a generic version or another drug. You’ll know before the patient leaves the chair if the prescription is covered by their insurance.” 

Trending article: 25 ways practice management software can save you money

	In addition, having access to patient images in the software means no more switching systems. “If you’re doing a procedure or diagnosis and you want to see an image from a few months ago, you can have access to it without having to switch to the imaging software,” Uretz says. 

	Finally, they offer automated recall. “If you have a patient visit and a follow-up is needed based on clinical rules you have put into the EHR, the system automatically can push out recalls in a number of ways to the patient, including the patient portal,” says Uretz. “That’s important because if you miss a potential recall, that’s business lost. Also, the next time a patient calls or comes in for a visit, the care team will be aware of any medical or dental alerts.” 

	7. “Will the system improve patient education?” 

	You’ll also want to check and see how user-friendly the system is in regards to patient education. Ideally, EHRs should help increase your case acceptance by improving the patient’s clinical experience and helping them understand treatment options. 

Trending article: Why dentists need to engage in discussions about periodontal disease

	“Previous to EHRs, you’d typically print out something for the patient to take home,” Uretz says. “EHRs will recognize details in the patient’s care while they’re in the chair, and with the push of a button, it’ll bring up an image or a video. If you have a tablet or a screen in front of the patient, you can show them in real time what you’re talking about. That’s powerful in helping the patient understand the procedure and agree that it’s necessary. If they don’t understand it, they’re not going to accept those cases. Some systems actually push patient education information to the portal as well. That allows you to interact more with the patient.” 

	8. “Does the system offer electronic referrals?”  

	EHRs can act as a patient tracking system if they enable electronic referrals, Uretz says. 

	“The traditional process is a long workflow, and you don’t get confirmation when the patient goes to the specialist that you referred them to,” he says. “With EHRs, you have the ability to refer that patient out from the point of care. It is sort of like a UPS tracking system: It’ll send the referral to the specialist, and when the specialist works on the patient, it could potentially send that information back to the patient’s record in your practice. So there’s an electronic footprint of the patient going through the referral system back to you, and all the information is in the system.” 

	9. “Will the system help build a medical home for my patients?” 

	With the rise of education on the oral-systemic connection, the push for health care providers from all specialties to communicate with each other is getting stronger. Being able to share data with all of your patient’s providers is an essential benefit of electronic health records. 

	The patient’s providers sharing information to better treat their patient’s whole body health is called the medical home, and it’s important to make it more efficient, says Uretz. 

More from Uretz: How to negotiate your EHR deal

	“You do that by enabling each of the health care providers to communicate in the patient’s health record,” he says. “That way, each provider has a full picture of what’s been done on the patient, and they can make decisions based on a full picture of the patient’s health, and not just what that particular specialist is seeing. Dentistry is being brought into that more now that we know more about the oral-systemic connection. The only way to do that electronically is with proper electronic health records. In the future, the goal is to have all of those providers be able to share information and we are getting closer to this objective. As we progress with dental EHR technology, some of the more innovative dental software vendors are prescribing to the patient record interoperability standard, which has already been fully embraced by medical software vendors” 

	But that may be more of a benefit in the medical field than in dental, says Dr. Lavine. 

	“One of the main hallmarks of EHR products, at least in the medical field, is interoperability: the ability to exchange information with other providers and software products,” Dr. Lavine says. “We don’t have that in dentistry. It’s controlled by a few major players who all have their own proprietary products, so there’s no easy way to exchange patient information. A Dentrix user can’t exchange information with an Eaglesoft or a Softdent user. The whole purpose of EHR was to make it easier for health care providers to share information, but that’s not the case in dental from my experience.”

9 Questions to Ask About EHR

	Times are changing, and the dental industry is, too. With shifts toward the dental service organization model, as well as exciting technology advancements, many dental practices will look very different in the coming years. But how will the changes affect your practice-and what will they mean for the long term?

	As I spoke with expert dentists-those who have been in the game for a while or are in touch with the goings-on in the industry-about the future of dentistry, most echoed what their colleagues were saying: Practices 

 will undergo a huge shift, leading to advancements in technology and the presence of multiple specialists in a single location. That shift will facilitate an increase in diagnostics and patient education. 

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	The pendulum is still swinging, and practices are still trending toward the dental service organization model (DSOs). As the model keeps growing, its wake will leave space only for certain kinds of private practice: the Neiman Marcus/Wal-Mart model, as one doctor says, and the solo-group practice model, as another doctor says. 

	The good news is that the space dentists will find themselves in will facilitate investment in technology. If dentists can adapt to the new frontier, they can be rewarded greatly. The same holds true for patients-at least for those who can afford the treatment. 

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	A lot will change in the next five years, if not in market availability, at least in ideas. In forecasting the future, there’s a lot we could talk about. The rise of minimally invasive dentistry, 3D printing or the increasing acceptance of sleep specialists are all going to change dentistry-but this article is not long enough to venture down every rabbit hole! Instead, let’s focus on two particular aspects of technology: imaging and artificial intelligence. 

	The trend toward DSOs is slowing down, but it’s already made its mark. And because it can help lighten the burden of student loan debt, which averaged $260,000 for 2016 graduates, that’s an appealing promise. While more than seven percent of licensed dentists are involved with corporate dentistry, the number is twice as high for dentists under 30.

	“When these students graduate, their debt load is so substantial that a lot of them go into corporate dentistry to pay the bills,” says John Flucke, DDS and technology editor for Dental Products Report. “What happens is they’re there for a while and they get used to a certain lifestyle and realize if they want to be in private practice they have to take a pay cut, but with increased personal responsibilities like families, it’s not going to happen. So, I think it will continue to grow and threaten private practice.” 

Trending article: Are the DSOs really taking over?

	And corporate dentistry has its benefits. “We’ve all known that that’s been coming,” says Brian Gray, DDS, of Giannini Gray Dental Partners in Washington, D.C. “The corporate model has come in and created greater efficiencies in dentistry, not just on the supply chain side, but more importantly efficiencies in the management side, which has been pretty much a cottage-type industry.”  

	DSOs won’t take up 100 percent of the market-but the space they leave will be available only to a certain kind of practice. 

	“I do think you’re going to see more individual dentists owning more practices, but not necessarily more large group practices coming out,” says Parag Kachalia, DDS, of Innovative Dental Concepts in San Ramon, California. “I think it comes down to a financial standpoint: All these groups are getting together to get the sum valuation that they can sell the private equity. That’s kind of what we’ve seen along the way, that dentistry has a cash flow standpoint that seems good from a Wall Street component to invest in a private equity standpoint. But there are fewer and fewer groups to gobble up. There will be some degree of saturation of group practices, and then it’ll start to swing back.” 

	At that point, he says, the trend will head toward a private practice model. But what kind of private practice? 

	“Some offices won’t be able to compete,” Dr. Flucke says. “Corporate fees are often lower than private practices, so I can see an independent practice having trouble. 

	“I think relationship building will always have a market, although it will shrink while corporate grows,” Dr. Flucke continues. “I think you’re going to see people who want a personal relationship with their doctor, office and staff. I see it often. People come in and say they were going to a corporate office but they didn’t like it. They feel it’s impersonal because there’s a lot of turnover. They didn’t feel like anyone knew them.” 

	While there will still be a demand for private practices, they won’t be based off a traditional model. Dr. Kachalia believes that there will be an increase in solo-group practices-offices where multiple, single practices operate in a given physical space. 

	“I think how we define the private practice model is going to change,” Dr. Kachalia notes. “Dentistry is an incredibly inefficient model and there’s a vast majority of offices that are unused for a significant portion of the week. Dentists may work four to five days a week, but it’s a six- to eight-hour schedule on a given day. There are 12 hours-plus that an office is not being used.” 

	Dr. Kachalia believes that, by sharing space while running independent businesses, dentists will benefit from being able to invest in technology together and streamlining rent. This could be another solution to the problem of dental school debt. “A big reason group practices are thriving the way they are is because they’re offering an opportunity for dentists coming right out of school to get a job where they’re doing dentistry and there’s potentially some loan repayment,” he says. 

	But ultimately, working for oneself will be the feature that wins. “There’s definitely a movement toward working for someone else and not having to worry about anyone else but yourself, but I think dentists historically have been co-owners,” Dr. Kachalia says. “We like to do our own thing. We don’t necessarily like to work for someone else forever. I do think the pendulum will start swinging back.” 

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	Dr. Gray sees three possibilities in the future of private practice. While the corporate model will comprise over half of all dentists in the future and be there to “treat the masses,” other practices will be smaller shops. “I think that those are going to be the ones that struggle the most because they’re going to fall between the Wal-Mart model and what people often call the Neiman Marcus model, which is high-end,” he says. “There’s not enough room right now to have that middle section survive.” 

	What’s left is what he calls the “dying mom-and-pop model,” which will be further divided into three categories: “The boutique dental practice, which is going to be a small, fee-for-service type practice; the cutting-edge specialty practice, which could be a practice that is focused in on one of the new things, from doing clear aligner treatment to sleep medicine to even just bleaching; and then the super practice, which will be a high-end, fee-for-service practice that will be team-based,” he says. 

	The team-based practice will have general dentists and specialists working together. 

	“To me, that’s going to be the ultimate model,” Dr. Gray says. “There is no way you can have any single dentist able to do all the different specialties, and I don’t think that personally at this point in my career I would want to be that kind of Jack-of-all-trades, master of none. Having those specialists who do these things on a regular basis work together under the same roof is going to provide an incredible patient experience. They’ll be able to offer cutting-edge technologies and stay abreast of what’s going on with the other specialties. When each specialist brings these things to the table through that workflow model, we can really change the way that we’re doing stuff.” 

	The benefit of the practice models of the future is that they will facilitate an investment in technology, primarily in the imaging world, according to Dr. Kachalia.  

	“Imaging will be expanded,” he says. “Not just radiation-based imaging, but non-radiation-based imaging, both for diagnostics and digital impressioning and the likes.” 

	Advancements in imaging will get a boost from the medical field as well. 

	“Years ago, we saw the proliferation of cone beam CTs,” he says. “That came from the predicate technology of digital CAT scans. In the next stage, we’ll see things like ultrasound and MRI come to dentistry.” 

	The hold-up with these technologies is that the area of the scans is so much greater in medicine than in dentistry, where the area of focus is measured in millimeters. The clarity needed in dentistry is not available in these technologies yet. But when it is, those will be the next big things in imaging, according to Dr. Kachalia. 

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	“The beauty of all those is that there’s no radiation involved in any one of them,” he observes. “Everyone knows that in a single office visit to the dentist, the radiation levels are really, really low. But I understand that people are more concerned with overall lifetime exposure to radiation. If we can find technologies to get rid of it completely, there’s no reason anyone would advocate that we must have radiation.” 

	He also anticipates dentistry borrowing from ophthalmology. “I think that optical coherence tomography (OCT) will come into dentistry in a form that can actually be used in dental offices,” he says. 

	As for the technology dentistry already uses, cone beam CT scans seem to be the most exciting due to their superior diagnostic capabilities. 

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	“I think cone beam CT is becoming the standard of care, especially in endodontics,” says Emily D. Hobart, DMD, of Bayside Dental in Anacortes, Washington. “I think they’re going to help us diagnose so that patients get the right treatment in the right amount of time and they have the best information to make the right decisions for their health.” 

	Erinne Kennedy, DMD, a dental public health resident at Harvard School of Dental Medicine, shared those sentiments. 

	“I’m excited about cone beam,” Dr. Kennedy says. “My practice has a lot of patients who come in and say, ‘This tooth feels funny,’ but diagnostically nothing comes of it. Radiographs show nothing because it’s 2D. I went to [the] Sirona 3D Summit and they were showing cases of patients who had complaints, but the X-ray didn’t show anything. Then they showed the cone beam, and it shows exactly what you wanted to see: something you couldn’t see or diagnose with any other method.” 

	Dr. Flucke is confident that digital caries detection will continue to be a growth industry. 

	“The visual aspect-taking pictures of teeth and then showing where decay is on the screen-that’s going to continue to advance,” he says. “There is a very strong possibility that ability may move into other devices as well.” 

	Dr. Gray values his role with research groups-the role of a clinician who gets to learn firsthand if products meet clinical acceptance in his field. And while more than half go back to the producer to be reconfigured, the ones that survive are “fantastic.” “Digital scanners come to mind,” Dr. Gray says. “We got our first about a decade ago and made our first purchase about eight years ago. We couldn’t practice without it.” He says the three he uses in his practice help with the workflow because information is automatically stored or sent to the right place. 

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	Where will the dental practice be in five years? Much more reliant on 

, he says. There are more uses for digital scanners than are currently put to use. The first is data capture itself. By doing scans on new patients as part of the comprehensive exam, dentists have their data stored, should they need it. Say the patient undergoes a trauma to his or her mouth: Clinicians can print off a perfect 3D model of the teeth before the accident. They’ll no longer have to guess. 

	“Digital scanning will play an integral role and be a standard of care in the initial comprehensive exam in the near future,” Dr. Gray says. 

	It’s already trending that way with a rapid increase in usage of digital scanners. 

	“I would say that more practices by far are going to be involved in digital impressions,” Dr. Flucke says. “I’ve seen statistics from dental labs that show that the number of cases coming in that are digital versus analog are rapidly increasing.” 

Related reading: Unpacking the differences in intraoral scanning options

	Digital photography can do the same thing. “There’s really no reason why we shouldn’t have every single dentist on every single patient be taking a landscape set of photos before we start treatment,” Dr. Gray. says “We should be taking eight photos: five intraoral and three extraoral, of every patient, at the initial clinical exam and every time we see a condition that is abnormal.” Dentists can also use the intraoral camera to look at fractures in the teeth, lesions and anything else that looks suspicious, he advises. And getting in the habit of capturing data at every turn will be beneficial in the long run. 

	Digital scanners have many benefits: They are faster than the traditional method, provide a much better patient experience and improve the workflow. But they have their limitations as well. So much so that Dr. Gray uses traditional impression material a quarter of the time. 

	“The biggest limiting factor with digital scanning that a lot of docs aren’t aware of is that a scanner can’t be used for every single situation,” Dr. Gray says. “If you’ve got anything at all that is obscuring the margin of your preparation - if there’s any fluid, be it blood, saliva or intra crevicular fluid, or if your margin is way subgingival and gingival tissue hangs over it - you can’t use a scanner.” 

	Because digital scanners capture only what’s in the line of sight, traditional impression materials are a better option for the situations he describes. 

	That’s all going to change in the next few years, thanks to multi-wavelength scanners. “Imagine having, in essence, a cone beam scan able to be used as a digital scanner that is able to take photos and create a 3D model of our patients,” Dr. Gray says. “We will be able to peel off the layers in images, starting with the skin and going down to the densest object, say teeth, from a single pass around the body.” 

	With the multi-wavelength scanner, clinicians will be able to visualize where the margin is underneath obstructions. 

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	The technology will be revolutionary, says Dr. Gray. “We’re not just going to use these to look at stuff like gross changes, say tooth eruption pattern or jaw development,” Dr. Gray explains. “We’re going to be able to use these also to look at decay interproximally and, yes, we’re at the point where we can look at lateral canals. Imagine being able to have this single scan to be accurate enough to properly perform endodontic treatment or use it for implant placement or [to] determine how large a fracture is, all on top of a real human face that’s in three dimensions.” 

	Having the accurate imaging systems sets the practice up well for what’s coming next: insane amounts of data and the new technologies that will not only be able to read said data but make diagnoses as well. 

	“I think the coolest thing that’s going to be available in the next year is a number of different software [options] that are out there that are able to look at minor changes in the oral cavity that occur over a long period of time,” Dr. Gray says. 

	If a patient breaks a tooth playing football, they can take a picture of their tooth with their phone and send the image straight to their dentist, who can then line the image up with the image on file to determine how much tooth structure was broken. “That was really cool when we first got it and started using it,” Dr. Gray remembers. 

	But he soon discovered a much bigger potential: the ability to track things he couldn’t see on a regular basis, such as recession. Trying to remember the condition of the patient’s gums at the last visit and taking a guess is not a scientific procedure. The question became: What if you could superimpose images of the patient’s mouth? 

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	The answer, Dr. Gray says, is improved accuracy. “The accuracy of this is around a half of a tenth of a millimeter-.061 I think right now-so that when we’re looking at changes in the mouth, we can literally measure and say when their gums are receding and diagnose why that may be,” he notes. “I see that [this] type of technology is going to play a huge role in us being able to have data.” 

	“There are lots of different imaging things that are out there today, and lots of data that we’re getting, but no one in dentistry is really mining that data from a diagnostics standpoint,” Dr. Kachalia says. “People mine business metric numbers, but there’s nothing today that takes all the data you have, whether from cone beam CT or caries detection or intraoral imaging, and puts that together to extrapolate a differential diagnosis.”  

	Kachalia says there is a huge potential that a computer could read data and make conclusions. 

 for dentistry,” he says. “There’s no Watson of dentistry today, or anything even close to it. I do think there’s this A.I. component that is going to be able to read our diagnostic input and tell us to some degree, ‘Here’s what this A.I. component believes is happening.’ It’s not going to be an absolute from a medical standpoint, but it’s going to give you guidance. It’s almost a diagnostic GPS system that will say, ‘Here’s what’s maybe going on.’” 

	Though people are talking about it, it hasn’t been done yet. Dr. Kachalia attributes that to the number of proprietary software on the market. But now that more companies are providing open-source software, that will start to change. 

	“We’re starting to get to the point where people are more open with the data, and now they’re asking how they should gather that data,” he says. “There are lots of algorithms that need to be run in order to accomplish that. How that’s going to play out is the unknown.” 

Trending article: The evolution of patient communication

	Data will also be the catalyst for another futuristic aspect of dentistry: augmented reality (think Snapchat). 

	“Those worlds are coming to health care,” Dr. Kachalia says. “That concept behind Snapchat’s filters will be involved in the medical world to show patients the potential of what they can have.” 

	He says showing patients a live composite image of their face will help show patients the picture before starting treatment. 

	“Two-thirds of people learn through visual communication versus auditory or tactile, but that visual role has not been in health care from an education standpoint in the past,” he says. “We used it from a diagnostics standpoint, but I think we’re bridging the gap so patients can understand what’s happening. A big part of understanding relies on them seeing value in their practitioner and not seeing it as a commodity. They start to see a rationale for picking a practitioner: someone who can truly educate them versus just handing them some words on a sheet. It’s taking informed consent beyond, ‘Here’s some text,’ to an actual visual standpoint of what’s happening.” 

	Of course, this is all down the road. But it’s a good idea to have a few basic technologies up and running to be able to get the data and all of its benefits. Step one, says Dr. Kachalia, is having an intraoral camera. Then it’s radiographs. 

	“Thankfully, we’ve seen a tipping point occur there,” he says. “Assuming you have those things, intraoral scanning is going to be the gateway to allow everything else to occur.” 

Trending article: How to use an intraoral digital impression scanner for restorative dentistry

	These advances in technology pose an interesting question: How do you make it available to everyone? This is something that was on Dr. Kennedy’s mind at the Sirona 3D Summit. 

	“That has to be a focus in dentistry as well-making diagnostics and tech like that available to all health centers,” she says. “When you have advancements like this, they need to apply to everyone. Because the cost of having that technology and the training is so astronomical when you look at it across an entire population of dentists or people, I don’t know if there is one answer, but it’s definitely a question that should be asked. It could revolutionize dental care for everyone.” 

	Dr. Gray’s suggestion for his own practice is to offer treatment pro-bono. 

	“The bottom line is that, where I see our practice five years from now is that if we continue to have a consistent, excellent experience, we have patients that can pay a fee for service and they value, appreciate and can afford what we do, it gives me the ability to go ahead and offer reduced fee or even free dentistry for patients that value and appreciate it but can’t afford it,” he says. “It gives me a chance to give back in that model. It’s going to be a real hard line between those practices that can do that and the corporate model that’s out there.”

Experts say the field of dentistry is shifting and new advancements will accompany the change. What will your dental practice look like five years from today?

The future of dental practices

	The goals of Scripps Center for Dental Care are to provide the very best in technology, amenities, techniques, and materials and the safest, most comfortable experience possible for their patients. 

	The goals of Thayer Dental Lab are to enhance the quality of patient care and offer dentists the latest advances in dental technology. 

	To facilitate those goals, the respective dentist and lab technician at these businesses - John F. Weston, DDS and Craig Yoder, CDT - utilize the digital workflow offered by 3M. Dr. Weston uses the 

 to take and send digital impressions to the lab, while Yoder uses 3Shape Dental Manager to design the restorations and 

3M™ Lava™ Esthetic Fluorescent Full-Contour Zirconia

“When it comes to submitting digital scans to the lab instead of sending rubber impressions in the mail, it’s just an incredible time savings on both ends,” says Dr. Weston. “With 

, we deliver everything via the internet and secure 3M cloud-based data storage system. Also, though most cases are model-free, when an actual model is used, the lab does not have the stone model work to deal with. They can order and receive in a few days a very accurate 3D printed, articulated trimmed and pinned model ready to go via 3M’s trusted SLA printing connection. And the models are cleaner and often more accurate than traditional stone and plaster models.” 

Technique: How going digital can revolutionize esthetics

	“Currently, scanning is becoming the new preliminary department, versus the traditional pour-and-trim,” says Yoder. “Of the restorations we produce, 97 percent are digital in one way or another.” 

 to drive a complete shift away from traditional waxing. They now utilize scanning and design software to either mill or print restorations. This shift has transformed the laboratory, from labor, staffing and equipment resource requirements. 

	“There’s a tremendous amount of IT involved, new computers, scanners and the licenses involved, and multiple 

,” says Yoder. “There’s also less labor involved in the artistic end of it in the ceramics department, resulting in more time to create beautiful, esthetic, functional, consistent restorations. We now have faster turnaround times, especially with the 

 and virtual manufacturing versus traditional impressions. Regarding cost, there are significantly fewer manufacturing steps by eliminating waxing, investing, casting/pressing or layering, so it’s more efficient in many ways.” 

More on 3M Lava Esthetic Zirconia: 3M introduces new super translucent zirconia

	That efficiency is also evident in Dr. Weston’s practice. 

	“Once you truly integrate a new workflow like digital scanning for impressions into your practice, it permanently and fundamentally changes how you structure everything,” says Dr. Weston. “Our chair time is less because adjustments are few and far between, so the entire team - from front office scheduling to supplies and assistants - has time to make the paradigm shift to fully take advantage of the benefits. Take, for instance, the simple conversion from analog to digital X-rays, the time savings, the consistent quality of image and the patient perception. I could go on. It’s really a game changer in my opinion.” 

	In the traditional workflow, a dentist would never imagine getting a case to a lab while the patient was still in the chair. It would be impossible. With digital scans, it’s typical. 

	“There are no bags, boxes, postage or packaging,” says Dr. Weston. “When working with implants, the time savings is dramatically reduced and we are able to provide for a custom abutment and crown simultaneously in a single impression visit, compared to multiple visits in the past. Since we are 100 percent digital for all our 

 work (including larger veneer cases, bridges and implants), it’s a benefit we see and use every day.” 

	The changes in the lab are just as striking. 

	“We only have one wax pot versus eight only six years ago,” says Yoder. “There’s very little waxing involved. Nearly all restorations are designed in 

 or some other form of CAD. With any conventional impression we receive, we digitize them by scanning them into 3Shape. With intraoral scanners, they arrive directly into a portal to our 3Shape Model Builder. That bypasses all the traditional steps of manufacturing. We are approaching 10 percent intraoral scanner impressions at this point and growing, compared to six percent two years ago. Intraoral scanners and virtual (model-less) crowns have been growing exponentially.” 

	The technicians then manipulate the contacts, function and contours of the restorations. 

	“We have each doctor’s parameters and preferences built in so we can predictably shorten their seating times,” says Yoder. “We nest those restorations in a software and immediately transport that data into one of our five-axis milling machines. The mills create an extremely accurate marginal fit and contour in the ‘green’ state zirconia. We then remove the restorations from the disc. We utilize three ShenPaz Sintra Plus ovens that are identically calibrated. 3M Lava Esthetic Zirconia is sintered at 1,500 degrees for five hours. We’re currently producing over 200 units per month, which is an increase of 100 percent since November 2016.”    

	“The biggest benefit I see is the reduction of chair time and cost savings related to not using impression materials, trays, adhesive and all the lab processes related to using analog models,” says Dr. Weston. “When I can predictably seat a crown in the fraction of the time, that allows me to move on to other procedures. The figures show that digital impressions can save the average clinician over 23 days a year based on an average of only two impressions per day. That’s a huge time savings, not to mention the cost savings related to that. We are just simply more productive with digital and it allows us to be more respectful of our patients’ time. That has real value and produces satisfied patients that gladly pay their bill and refer their friends. It’s a win-win in my eyes!” 

	It’s not just the digital workflow that makes a difference. The quality of Lava Esthetic Zirconia increases productivity in the lab as well, according to Yoder.  

	“It has a shorter sintering cycle time compared to most other zirconias: five hours compared to eight hours or more,” says Yoder. “Another important enhancement is that it has a flexural strength of 800 MPa

, which is higher than other cubic zirconias currently on the market. The advantage is its ability to span up to 3-unit bridges anywhere in the mouth.” 

	Because Lava Esthetic Zirconia mills “like butter,” Yoder says it has superb margins and less chipping than other zirconia products he has worked with. 

	“A substantial benefit is the intrinsic enamel translucency,” he says. “Controlled by how it is positioned when you nest it in the milling disc, it has a 3-millimeter incisal translucency, and gingival to that, it has a 3-millimeter transition to the body color. That beautiful, natural incisal blend provides very high esthetics in a restoration with monolithic strength, without the labor of layering. It also eliminates the chance of chipping and delamination, which means fewer remakes.” 

	 And of course, fewer remakes leads to time saved, a benefit noticed by everyone involved: technician, dentist, and patient. 

Next: What has the patient response been? 

	“Patients are amazed at the time savings and notice the difference as well,” says Dr. Weston. That goes above providing a greater level of convenience to the patient: it’s about demonstrating a higher standard of dentistry. “They see the benefit of technology and are proud to be at an office that uses the most modern equipment. They recognize the quality.” 

Trending article: How to use the 3M True Definition Scanner for Invisalign treatment

How 3M True Definition helps the lab and practice meet their goals 

Built in preferences shorten seating times in the lab. 

	“We have always believed in using the best equipment and materials, so adding digital impressions was a natural fit for us,” says Dr. Weston. “We are a true multi-specialty practice, with board-certified specialists in each area of dentistry, so we have many different providers using digital equipment for various reasons all for positive outcomes. For example, using digital impressions merged with our onsite 3D cone beam X-ray system allows us to collaborate between surgeons and restorative doctors. 

	"We now plan and execute complex implant cases right in our office with a high degree of accuracy and predictability using milled and printed surgical guides. This planning can all be done ahead of time so the patient surgical procedure is shorter. That’s always better for the patient. It’s not really one digital tool or one provider using digital impressions, but a combination of all team members using all the technology available at their fingertips for the benefit of our patients. That’s our philosophy, and digital makes it work better than ever before!” 

3-point bending strength according to ISO 6872:2015; qualified for Type II, class 4 indications: crowns, 3-unit bridges with one pontic between two crowns, inlays, onlays and veneers.

How the 3M™ True Definition scanner and Lava Esthetic Zirconia help streamline the lab workflow.

The digital workflow with 3M

	Near the end of last year, Robertson Dental Lab relied solely on their five milling units to create dental restorations. Nearly four months later, they are preparing to invest in an equal number of 3D printers. With three so far, they are well on their way.

, located in Lompoc, California, purchased a 

 in December and has gotten two more since then.

	Because it has completely changed their workflow, says general manager Paul Lamontagne, they plan to get two more soon for a total of five. At that point, the lab will have an equal number of 3D printers and milling units.

	The Form 1, Form 2’s predecessor, is the world’s best-selling printer, so one can imagine the possibilities for the upgraded Form 2, especially at a sub-$4,000 price point. The Form 2 printer is $3,499, which makes it easier for a productivity-focused lab like Robertson Dental Lab to invest in a few.

Trending article: 5 workflows changed by 3D printing

How the Formlabs Form 2 3D printer helped one lab achieve an ideal workflow-at an affordable price.
