Windows 10 – Should I Wait?

By Steve McEvoy, Technology Consultant

steveMMicrosoft has recently released the latest version of its operating system (OS) for PCs – Windows 10 (let’s call it WinX).

This is the first time Microsoft is offering the upgrade for free to existing users of Windows 7 and 8 (until July 2016 – and maybe longer).   They are intending to make upgrades to their OS less of a big deal in the future, giving it away and moving to a more automatic update format.   Apple and Android have been following this model for years.   It’s a good idea for the most part – keeping your OS up to date means it has the latest security & features.

WinX Notifier

Screen Shot 2016-03-21 at 4.47.51 PMMany of you may have seen a little notifier popping up on your PCs prompting you to reserve or upgrade to your free copy of WinX now.   With great joy and vigor many of you have done just so.   But is this a good idea? Staff clicking on it can trigger a disaster if this isn’t thought through.

Upgrading any Microsoft OS in the past has typically been an ordeal. You have to consider several things before you undertake an upgrade:

  • Will the new OS have drivers that support my hardware (video card, sound card, etc.)?   Often they don’t for older hardware (even systems a year old may not have drivers). Checking with your hardware vendor in advance is a good idea (for example going to the support website for Dell or HP and look to see if WinX drivers are available for your PC).
  • Will it work with all my peripherals?   Often you need specific OS drivers from Vendors to make these work.   Check with your vendors in advance to be sure they are available for things like:
    • Printers
    • Document Scanners
    • Signature Pads
    • Credit card scanners
    • X-Ray systems (this is usually a HUGE problem – they lag far behind)
  • Will the applications I own work on WinX?   You need to check with each vendor in advance if they full support WinX. Many don’t immediately after the initial release (and still aren’t as of this writing).
    • Practice Management software (like Dolphin, Orthotrac, Dentrix, etc.)
    • X-ray system software (like Romexis, Cliniview, Anatomage, etc.)
    • Antivirus software (most need upgraded to support WinX)
    • Backup software
    • Even Microsoft Office (older versions are not fully supported)
  • Will I have to retrain my staff? The changes in the user interface often give less adaptable staff fits.

Initial reviews of WinX are mixed. They’ve added some new features (Cortana assistant and the new Edge web browser) – most of which don’t matter to a Dental Specialty Practice.   They’ve changed the look and feel of the Desktop and Start Menu system yet again (the Metro interface is gone thankfully).   As with any new version of their OS, lots of little problems are being discovered as it rolls out to millions of users.

What would I do?

Screen Shot 2016-03-21 at 4.48.02 PMMy stance is typically to wait out the initial release and let others debug the 1.0 version. At the time of this writing Microsoft has released build 1511 (which is essentially Service Pack 1), and this generally marks the ‘safe to go in the water’ if you’re interested.

For your Home I’d say the risks of upgrading are pretty low if you have fairly recent hardware and you might want to give WinX a try. I’d still take time to confirm if your peripherals (like your printers) are compatible.

For the Practice I would recommend waiting until there was a compelling reason to change. I believe it’s easiest on the staff if ALL the PC’s in the Practice are on the same version so they have a consistent experience and don’t have to keep adapting.   If you were getting all new PCs, I’d seriously consider making the change. If you have a fleet of Windows 7 PCs that are working fine, I wouldn’t bother.

If you have your heart set on jumping in, involve your IT person. They can do the checking for you and advise you on a pathway and any bumps in the road that might be expected.

Smartphone-based orthodontic monitoring: the big brother in our patient’s mouth

by Domenico Dalessandri, DDS, MS, PhD

Screen Shot 2016-03-11 at 11.06.09 AMNowadays almost all of us have a smartphone and we use it hundreds of times during the day checking incoming e-mails, surfing through the web and sharing our thoughts and pictures online within our social communities. This is the “permanently online” era and our patients ask for immediate information supply and assistance request satisfaction.

Since sometime orthodontists have used text messaging apps like WeChat or WhatsApp to communicate with their patients, to remind them the next visit, to solve an emergency or replying to a late doubt, or even checking the oral hygiene status or the cooperation level with removable appliances. There is a growing evidence in the literature showing the efficacy of these “App based” monitoring protocols in ameliorating oral hygiene and reducing treatment duration, bracket bond failure, and failed or late attendance [1-2].

Commercial interest regarding patient monitoring has also increased progressively and nowadays there are few apps especially designed for this purpose. In all these systems the orthodontist has his own dashboard on reserved area in the company website that can be used to invite patients to download the app in their smartphones and to visualize their smile pictures.

SmileTrackerTM (TP Orthodontics) also allows visualizing a time-lapse video, based on daily pictures taken by the patient during the monitoring, of the treatment progress. Furthermore this app has a rewards-based system in order to keep patients engaged throughout the monitoring and it also allows them to share their progresses through their own social profiles.

Dental Monitoring® allows patients to take smile pictures every 2 weeks in case of fixed orthodontic treatment or even every week for invisible aligners treatments. Doctors can also ask for a supplementary exam whenever they want, sending through their personal homepage a specific invitation that is forwarded by e-mail to the patient. This system requires doctors to send patient dental impressions before monitoring begins, because it utilizes a specific algorithm that allows calculating teeth movements based on pictures 3D matching and superimposition on the initial virtual models. For this reason patients are required to take 13 pictures for each exam from different angulations focusing on both single arches and on their position in occlusion. Three more pictures are required for patients treated with invisible aligners, in order to check each single aligner fit. This system, apart from calculating through the algorithm tooth by tooth displacement as mesial/distal, intrusion/extrusion, retraction/advancement, rotation, inclination and angulation variations, provides pictures observation by an orthodontist that looks at oral hygiene level, aligners fitting, possible presence of teeth abrasion, decays or brackets failure, sending a warning to the treating orthodontist in case of any unexpected event.

Could these systems become important tools allowing us to improve our treatments efficiency and quality? Is it credible that “virtual” appointments could in some occasions substitute the traditional “physical” appointments? Will our patients be available to be continuously controlled by this orthodontic “big brother”?

It is hard to foresee the future. The possibility for patients, especially if they live far from the orthodontic office, to save time and money by reducing the number of visits having the same, or even a better, accuracy in treatment progress control, can be universally recognized as positive factors fostering the diffusion of these systems.

Are we ready for this further step forward along the digitalization path of our beloved orthodontic specialty?

1: Zotti F, Dalessandri D, Salgarello S, Piancino M, Bonetti S, Visconti L, Paganelli C. Usefulness of an app in improving oral hygiene compliance in adolescent orthodontic patients. Angle Orthod. 2016;86:101-7.

2: Li X, Xu ZR, Tang N, Ye C, Zhu XL, Zhou T, Zhao ZH. Effect of intervention using a messaging app on compliance and duration of treatment in orthodontic patients. Clin Oral Investig. 2015 Dec 2. [Epub ahead of print]

Domenico Dalessandri qualified in Dentistry from the University of Brescia, Italy, where he received specialty training in Orthodontics. He obtained his PhD from the University of Torino discussing a thesis entitled “Cone Beam Computed Tomography: accuracy and reliability”. He received a research fellowship in “CBCT applications in Orthodontics” by the University of Trieste. Currently he is Adjunct Assistant Professor at the University of Brescia.

He has additional clinical research interests in: indirect bonding; self-ligating braces; use of mini implants and miniscrews; lingual orthodontics; Invisalign; cleft lip and palate; impacted teeth; 3D technology and virtual treatment planning; CAD-CAM; corticotomy and piezocision.

HIPAA: Encryption is NOT Required…What?!?

By Charles E. Frayer[1], JD, MS, HCISPP, CIPP, CIPM

Introduction
cfrayer
No, that headline is not a misprint. Contrary to common assumptions—and what many email encryption providers may tell you, Congress, in its infinite wisdom (stop laughing, please) decided that the Health Insurance Portability and Accountability Act (HIPAA) should not—and, therefore, it does not—require the use of encryption to secure your patients’ private medical data (aka, electronic Protected Health Information or ePHI).

WARNING: IF YOU STOP READING NOW AND SIMPLY DECIDE THAT YOU DO NOT NEED ENCRYPTION, YOU MAY WAKE UP ONE DAY TO THE WORST FINANCIAL AND PUBLIC RELATIONS NIGHTMARE IMAGINABLE. SO, READ ON…

Required vs. Addressable: What’s the Difference?
In HIPAA, Congress adopted two types of implementation specifications—“required” and “addressable.” Those labeled “required” must be implemented or it will be deemed an automatic failure to comply with the HIPAA Security Rule. On the other hand, those labeled “addressable” must be implemented only if, after a risk assessment, the covered entity (that’s you, if you’re a Health Care Provider, a Health Plan, or a Health Care Clearinghouse) has determined that encryption is a reasonable and appropriate safeguard for managing risks to the confidentiality, integrity and availability (CIA) of ePHI. A brief sidebar about the CIA triad: confidentiality protects against unauthorized disclosure; integrity protects against unauthorized modification or destruction; and availability protects against disruptions to access and use of ePHI. Okay? Now, back to our story…

However, if you determine that encryption is not reasonable and appropriate (think about this carefully), then you must document your rationale for that decision and do one of the following: (a) implement an equivalent alternative to encryption that is reasonable and appropriate; or (b) if safeguarding ePHI can otherwise be achieved, then HIPAA even allows you to choose not to use encryption or any equivalent alternative measure, provided that you also document the rationale for this decision.[1] Shocking, isn’t it? Yes, Congress effectively (is that an oxymoron?) allows you to do nothing, provided you can and do back it up.

Now, if you’ve thought about that carefully, you’re probably wondering something like, “What if HHS audits me and they don’t agree with my carefully documented rationale for deciding that encryption is not reasonable and appropriate to protect my patients’ private medical data?” Perfect question! And therein lies the problem. It is difficult (impossible?) to even imagine a situation for which it would be “reasonable and appropriate” to decide not to use encryption to protect ePHI (remember, that lowercase “e” stands for “electronic”). So, even though HIPAA does not literally require encryption, it effectively requires encryption because there is no reasonable and appropriate alternative for protecting ePHI.

In other words, when it comes to using encryption to protect ePHI, there is little (if any) difference in Congress labeling it as “addressable” rather than “required” because not using encryption is simply too risky for your patients’ ePHI and, therefore, even riskier for your business.

Encryption: HIPAA’s Data Breach Safe Harbor
Under the HIPAA Breach Notification Rule, there are essentially two types of ePHI—unsecured (i.e., unencrypted) and secured (i.e., encrypted). Under HIPAA, every breach of unencrypted ePHI requires you to provide time-bound notifications to: (1) affected patients; (2) the Secretary of HHS (i.e., the federal government); and/or (3) prominent local/state media outlets. This, of course, will put you at risk of federal and/or state investigations, fines, possible lawsuits, and the worst kind of public relations disaster imaginable, which will almost certainly result in lost business.

But there is good news…no…GREAT NEWS!!! Under the Breach Notification Rule, encrypted ePHI that is “breached” (e.g., lost, stolen, or accidentally/intentionally sent to the wrong recipient) is not considered a breach at all because ePHI that is encrypted cannot be read or otherwise used without the key(s) required to decrypt it. Consider some of the risks of emailing your patients’ ePHI unencrypted versus sending it via encrypted email, as follows:

Screen Shot 2016-02-18 at 4.27.19 PM

So, if you use it, encryption is your lawful HIPAA-endorsed safe harbor against everything you want to avoid in the event of a breach of ePHI. Going back to our previous segment, even if you somehow came up with that rarest of all situations—where using encryption to protect ePHI was not reasonable and appropriate, you still need to use it because doing so gives you a complete “out” when the worst of all possible ePHI scenarios—a data breach—occurs (i.e., you get to simply walk away).

In summary, although HIPAA does not literally require encryption, Congress nonetheless has effectively mandated its use because (i) it is all but impossible to think of a real-world situation where encrypting ePHI is not reasonable and appropriate; and (ii) if you choose not to use it, you are exposing your business to a plethora of regulatory, legal, public relations, and/or financial risks that are easily avoidable—by simply using encryption.

[1] Charlie Frayer is a Michigan licensed attorney and Florida Authorized House Counsel serving as General Counsel and Chief Privacy Officer at Protected Trust, LLC, the leading provider of Simple Email Encryption with 24×7 free and unlimited support via phone, email, and chat.

[1] See: 45 CFR § 164.306(d)(3) detailing the difference between “Addressable” and “Required” implementation specifications at http://www.ecfr.gov/cgi-bin/retrieveECFR?n=sp45.1.164.c#se45.1.164_1306;

45 CFR § 164.312(a)(2)(iv) labeling encryption and decryption as “Addressable” at http://www.ecfr.gov/cgi-bin/retrieveECFR?n=sp45.1.164.c#se45.1.164_1312; and
the HHS HIPAA Encryption FAQ at http://www.hhs.gov/hipaa/for-professionals/faq/2001/is-the-use-of-encryption-mandatory-in-the-security-rule/index.html

When Less is More, Regarding Radiation

J-Martin-Palomo-Headshotby Juan Martin Palomo DDS, MSD

We all know Cone Beam Computed Tomography (CBCT) by now. It allows a non-invasive, usually less than 10-second capture of the craniofacial anatomy, which is able to create all possible traditional 2D radiographs, giving far more diagnostic information. Probably the main mentioned reason of why it has not replaced the traditional panoramic and cephalometric radiographs in clinical orthodontics, is radiation. Depending on the settings used, it could expose the patient to more radiation than that of a ceph and pano. The radiation would still be considered low, according to the American College of Radiologists, and is less than the additional annual cosmic radiation that somebody living in high altitudes, such as Colorado, receives, but nevertheless, more than a ceph and pano. But this is no longer the case, for a while.

Most major CBCT manufacturers have now a low-dose scanner in the market, which allows the 3D image to be captured, with less radiation than a panoramic radiograph. It givless is more Palomoes a complete 3D image, where a pano, ceph, and complete 3D view can be used, for less radiation than that of a distorted pano. How is this possible? The answer is “capturing technology”.

When a low dose 3D image is captured, the scanner does not go all 360 degrees around the patient’s head. Sometimes it is just 180 degrees. The 3D image is basically a combination of several static images (radiographs) taken while the scanner rotates around the patient’s head. In a low dose option, the number of images captured are less than 200, as opposed to the usual 300-600. When a panoramic radiograph is being taken, the x-ray beam is “on” the whole time, beeping, while going around the patient’s head. In a low dose CBCT scanning, pulse technology is used, so the x-ray beam is only “on” for a fraction of a second while taking a quick image, turning itself “on” and “off” automatically, resulting in a total radiation exposure of about 2 seconds.

All this in combination with low radiation settings, results in total effective radiation to the patient in the teens or low twenties, compared to high twenties for a pano. And in this numbers game that is effective radiation, the suggested safety threshold is 30 microsieverts. Anything below 30 microsieverts can be considered low, and fair game.

Now for the very necessary disclaimers. This does not mean that because we can get to less than 30 microsieverts we should scan everybody. Zero is still less than 30. So if a radiograph that can answer the question clinically posed has already been taken, retrieve it and do not take an additional one. If no radiograph is necessary, don’t take one just because you can. But if a radiograph is needed, and a low dose CBCT is an option, I would have a hard time justifying a ceph and pano, as opposed to a low dose CBCT. And to take a pano or ceph before taking a low dose CBCT would also be unnecessary additional radiation to the patient.

The low dose CBCT alone has more than sufficient image quality for what we need in orthodontics. I have seen images from several manufacturers, and this is clearly a situation where less radiation to the patient is also more information to the doctor. What better win-win that this can we ask?

Have You Talked to Your Telecom Vendors Recently?

By Anthony M. Puntillo DDS, MSD

Dr.-Puntillo-PictureMany of you have no doubt seen the television commercials announcing the merger of AT&T and Direct TV. This merger is just another sign of the digital transformation the United States telecommunication industry is undergoing. This transformation is being driven largely by an insatiable consumer desire for data and bandwidth. If you have transitioned your practice to digital, and many have, chances are high that you discovered your office hard drive was full and needed to be upgraded. Furthermore, single location practices are becoming more rare and it can be challenging to access all of this additional data when and where you need it. This issue is even more pronounced in the increasing number of practices that utilize 3D CBCT machines, as the DICOM files generated by these machines can be as large as 700 megabytes.

My practice consists of four office locations, three doctors, and three CBCT machines. All our locations are networked to a single sever and all patient data is securely accessible at each location and externally via a virtual private network (VPN). Our Voice over IP (VoIP- see Dr. William Engilman’s post from May 2012) telephone system connects all our offices and staff seamlessly. To make all these systems work we require stable bandwidth and lots of it. That bandwidth comes at a significant monthly fixed cost for our practice. Recently, in an effort to make sure we were getting the most for our money, we asked our IT consultant to review our contracts and plans with all our telecommunication network providers (i.e. AT&T, Comcast, etc.). Their review found that by bundling some services (i.e. phone, internet access, etc.) additional bandwidth, and subsequently improved efficiency, was available for a similar monthly cost. In the cellular world, companies such as AT&T, Verizon, T Mobile, and Sprint are investing heavily in infrastructure upgrades. These upgrades are being used to offer consumers deals that were unheard of just 12 months ago. If you have not reviewed you offices telecommunication vendors and plans within the last 12 months, I would encourage you to use the slower time in your office this fall to do so. You may find significant cost savings or improved services are also available.

Nanotechnology: From Small Scale to Great Innovations

By Dr. Celestino Nobrega

dr Celestino Nobrega 2007Are you prepared for the amazing benefits and innovations that Nanotechnology will shortly bring to orthodontics? Richard Feynman (http://www.feynman.com), an American theoretical visionary physicist, introduced Nanotechnology as a science that embraces the capability to see and to arrange atoms and molecules according to a particular convenience or goal.

Nanotechnology involves the development and utilization of structures, devices, and systems that have properties and new functions due to their small size. A nanometer is one-billionth of a meter. For reference, consider that there are about 25,400,000 nanometers in an inch, and a single sheet of paper is about 100,000 nanometers thick.

The NNI (National Nanotechnology Initiative) is a U.S. Government research and development initiative that is focused on delivering the shared vision of “a future in which the ability to understand and control matter at the nanoscale leads to a revolution in technology and industry that benefits society.” NNI is chartered to develop a framework for sharing strategies in order to support nanoscale projects. Common goals, strategies and priorities are now being drawn for distinct science fields, such as biology, engineering, chemistry and, of course, materials science. With this support, nanotechnology R&D is taking place in academic, government, and industry laboratories across the United States.

As Orthodontics progresses into a refined science and with the support of technology advancements, unimaginable results can be achieved in the near future, especially when our specialty can leverage nanotechnology innovations such as selective biosensors. The oral cavity can be considered as an important source of information that could be extremely helpful not only for orthodontic treatment, but also for early stage diagnosis and monitoring of systemic diseases. It’s largely known that the exhaled human breath contains several Volatile Organic Compounds biomarkers (VOCs). Accurate detection of these VOCs can provide essential information for the diagnosis of those diseases. For example, Acetone (CH3COCH3), H2S, NH3, NO, and Toluene can potentially be used to evaluate diabetes, halitosis, kidney malfunction, asthma, and lung cancer, respectively.

Breath analysis, pH level and temperature data can be captured and processed by multiple sensors and could potentially reduce the medical diagnostic costs for patients suffering from chronic illnesses. In addition, patients’ quality of life could be improved. For example, diabetic individuals could possibly benefit from using non-invasive nanostructured hemitubes Silicon-doped (WO3) films to sense acetone exhaled breath levels, which can eliminate painful and invasive fingertip pricking.

As I observe the emergence of recent technology advancements within orthodontics, I can envision a future of innovative orthodontic portable devices that can accurately capture, track and transmit these previously mentioned biological signals.

In this category, we can include the exciting new innovation of dental movement acceleration devices (periodontal tissue activation by vibration). Along with achieving their primary objective of delivering pulsatile forces to accelerate tooth movement and to reduce treatment time, these devices could also be used to capture intra-oral data through the action of nanosensors and wirelessly transmit this information to personal mobile devices and laptops. The remotely collected data can be stored on the cloud to create an intelligent system for support of clinical decisions. This robust wireless communication and database creation has the potential to support multiple users throughout the orthodontic treatment process:

  • Orthodontist: electronic health records (EHR) enrichment; treatment plan refinement according to patient features; suggestions for treatment plan improvement according to case’s evolution; warning signals and alerts to monitor patient’s general and intra oral health.
  • Patient: real time communication with the Orthodontist or their staff through smartphone connection; treatment status check; sharing treatment experiences with other potential patients; automatically get FAQ answers.
  • Companies, industries and laboratories: helpful database for new products designs, services and needs.
  • Scientific research: Database for systematic reviews, Meta-Analysis.

So, are you prepared for “small” technology and big changes?

 

 

Sending Sensitive Patient Data via E-mail

Foto-StudOnBy Dr. Andreas Detterbeck

The communication between clinicians via E-mail is fast, easy, cheap and widely used. But sending an unencrypted E-mail is as safe as sending a postcard. So, numerous parties have full access to E-mail-correspondence at all time. Violations against the patient privacy could cause dramatic consequences – depending on national laws, some of these solutions may even result in prosecution of the clinician (see HIPAA).

There are many commercial solutions to encrypt your communication, but if you are firm and experienced in using computers – you should at least know how to download and install software – there is no need to rely on any company. You don’t have to worry about high fees or losing your correspondence if your preferred encryption-business crashes. In this blog I want to suggest a few ways how to encrypt your E-mail communication easily and (almost) free of charge:

screenshot

Encryption of E-mail Communication by S/MIME
If I don’t want that my mails can be read by anyone except the receiver of the mail I have to convert the text in some sort of coded or encrypted form. Because it is not easy to invent an encryption of your own and sharing that idea with your communication partner a standardized tool would be very helpful. And this is where the Secure/Multipurpose Internet Mail Extensions (S/MIME) come in: S/MIME offers encryption and signing of E-mails in a standardized and reproducible way. Most current E-mail programs and free Webmail providers support this process.

Subsequent I will give a step by step introduction how to implement S/MIME in your mailing process:

  1. First of all you have to make sure you are using an E-mail program with S/MIME support (Mozilla Thunderbird, Microsoft Outlook and many more)
  2. Next you have to buy or even just create a certificate from a big commercial or non-commercial certification authority (CA). You may find some references here.
  3. Now comes the hardest step – but don’t worry you’re almost done:
    Deposit this personal-certificate in your E-mail program with S/MIME support. This process is very different depending on which program is used. Here are two useful how-to-links for the most common software:

Microsoft Outlook
Mozilla Thunderbird

  1. Users who have completed these steps are then ready to send digitally signed E-mails and receive encrypted messages (You sign a message when you want to prove that the mail comes from you and no modification of the text has been done during the transit).
  2. If users want to send encrypted E-mails of their own – and not only receiving encrypted mails – the receiver needs to have an S/MIME certificate, too.

For security reasons, your user certificate will normally remain valid for one or two years and is available from the CA for a small fee or even free of charge.

Conclusion
Maybe you think this sounds all strange to me and way too much work is required. There has to be an easier, less cumbersome solution.

But we don’t have the easy solution yet.

Of course you can pay a company for securing and encrypting your communication, but what happens if the company is insolvent or they decide to wind down the operations. What happens to your documents? There are providers that will allow you access to your data, but this may not be the case for all providers, so make sure this is the case before you sign up.

For use in daily clinical practice, I definitely recommend E-mail encryption by S/MIME. It is an IT standard since 1995 and a long term support is presumably. At least the corresponding doctors should have any form of secure communication.

Do not forget: The use of cryptography before sending patient data via E-mail is mandatory! If you are not sure how to encrypt your E-mail communication it is better to relinquish sending private patient data via the internet.

This blog-entry is based on:

Electronic transfer of sensitive patient data.
Detterbeck A, Kaiser J, Hirschfelder U.
Int J Comput Dent. 2015;18(1):45-57.
http://www.ncbi.nlm.nih.gov/pubmed/25911828

3D Printing and Orthodontics

By Dr. Christian Groth

As we move towards the 2015 AAO Annual Session in San Francisco many of us will be making check lists for items to investigate at the exhibition hall and lectures. Anybody who has attended recent meetings has seen that intraoral scanners are a hot topic. Every year new products are being released, or updates to current systems are offered. Intraoral scanning has opened the door for additional technologies within (and outside of) the orthodontic office. Dr. John White wrote a very informative blog post in February talking about the use of intraoral scanning for same day consultations (click here to read it). As more people are offering clear aligner therapy (including general dentists and the mail order aligner system that we all know about) it is time that we differentiate ourselves as orthodontic specialists. One way in which we can do this is to incorporate 3D printing into our daily practices.

3D printing, also known as additive manufacturing, is a process by which a physical object is created from a digital file (check out a video of 3D printed models here). There are several different types of 3D printers available that range in price from a few hundred dollars to almost one hundred thousand dollars. They all have one thing in common: they build models layer-by-layer with a build platform that moves vertically. The smaller the layer thickness the better looking the model will be. The four most popular types of printers are: Fused Deposition Modeling (FDM), Stereolithography (SLA), Digital Light Projector (DLP), and Polyjet Photopolymer (PP). Without getting too technical here is how each basically works. FDM involved heating up a thin strand of plastic resin that comes off of a spool and is deposited in layers as thin as 100 microns. SLA and DLP technologies are similar in that they utilize a vat of liquid, photosensitive resin. When the light hits the resin it is cured and platform moves to enable the next layer to be cured. The different between SLA and DLP is that SLA uses a single laser point to draw an image whereas DLP uses a projected image to cure a whole layer simultaneously, which allows the printing process to move faster (think of this as the difference between drawing a picture and stamping a picture). PP printers are probably the most popular in dentistry and use inkjet technology (yes, just like your desktop printer). Liquid resin is jetted out of nozzles in an extremely accurate fashion and cured by a UV. Layer thickness of SLA, DLP, and PP printers can be as low as 16 microns (for your reference the average piece of paper is 100 microns thick).

While the technologies differ between printers what truly sets them apart is the quality of the parts. Cheap printers are made from cheap parts that can degrade over time and result in inaccurate models. It is truly a case of you get what you pay for. So if you are in the market for a 3D printer to be used in your practice, buy the best one that you can afford.

3D printed models can be used for anything in the orthodontic office.   The most practical use is for retention and relapse treatment. A major downside to stone models is that they are often destroyed during the retainer fabrication process. 3D printed models do not get ruined and can be used as many times as necessary for retainer fabrication. Imagine being able to print a model, make a clear retainer, and mail it off to a patient who is away at college. What a service you have just provided to your patient and they never stepped foot in your office! Pairing 3D printing with one of several software programs available allows us to create sequential setups/models for minor tooth movement. By controlling the process we control the overhead and thus have the ability to pass these savings on to the patient. Another great service that we can offer our patients if they have a lapse in retainer wear.

Whatever your practice is like there is a place for 3D printed models in it. While you will pay a little bit more for the physical model, the longevity, versatility, patient excitement, and ability to virtually eliminate alginate impressions from your practice will pay off in the end!

Simplifying Management of Satellite Offices

By Matthew Larson, DDS, MS

Matt LarsonIn the current economy, satellite offices are frequently utilized by orthodontists to increase their area of draw and patient base. Most orthodontists and consultants feel that the additional income offsets the additional overhead expense, but managing multiple office locations clearly requires more effort than maintaining only one location. However, current technology has helped make managing multiple locations easier. One dramatic example that most orthodontists now utilize is electronic charting, so that patient information is easily available at all office locations. Here are a few other tips and tricks to consider:

  • Centralized/Cloud-Based Documents: Most offices ensure that all patient information in their practice management software is either on a centralized server or cloud-based, but many offices are not as attentive to all of their supporting documents. Your satellite office should be able to run exactly like your primary office if desired. It is relatively easy with current technology to ensure all computers have access to centralized training manuals, patient handouts, and current projects. More limited access can be setup for the doctor and select staff to access more confidential information. Multiple methods can be used to achieve this, such as a shortcut to a shared document folder on the server (if a terminal server is used at the satellite office) or online cloud-based storage such as iCloud, Google Drive, or Dropbox. Please note that iCloud and Dropbox are not HIPAA compliant and Google Drive requires some adjustments to be HIPPA compliant, so these are not ideal solutions for PHI. The goal is that each practice location should have electronic resources in the same location for easy reference and there should be little to no effort to keep them synchronized.
  • Mileage tracking mobile apps: Deducting business mileage or tracking business miles on the company vehicle can provide a nice tax savings, but maintaining an accurate ledger to satisfy the IRS can be difficult. Multiple mobile apps are available to help keep an accurate log of business miles, such as Mileage Log+, MileagePad, Auto Miles, and Triplog. Some apps will automatically track when you are driving and then miles can be categorized later. Most allow you to export spreadsheets or expense reports for a nice end-of-year summary. Prices are generally under $10.
  • Remote locks and thermostats: I may be slightly biased since our practice is located in Wisconsin, but having a remote thermostat to ensure that heat is turned down when we are not at our office and that the office is warm when we arrive really helps staff morale at the start of the day! Also, there are coded locks available for your front door that allow you to remotely issue one-time use codes for contractors to access the building. Multiple permanent codes can also be set, which allows you to monitor who is entering your office. For example, cleaning staff can be given a unique code so you are aware of when they are onsite. These generally are a few hundred dollars to install, but avoiding extra trips to let in contractors or paying for additional heating/cooling bills can make it worth the expense.
  • Phone lines: Phone systems are a much larger topic, but it is worth at least briefly mentioning that having lines ring at only one location and going to voicemail if they are not answered is outdated. For offices with multiple locations, some type of VOIP system should be strongly considered, which allow lines to be answered and transferred independent of geography. Even with a traditional phone system, look into the additional features offered by the phone company. Generally, lines can be forwarded on certain days of the week and calls that are not answered in a certain amount of time can be forwarded to the other office (assuming the other office is staffed).

Overall, managing a satellite office can be less stressful using current technology, but some effort must be spent up front to design the correct systems and to implement them.

The Digital Generations

By Anthony M. Puntillo DDS, MSD

Dr.-Puntillo-PictureThe majority of the U.S. Workforce today is comprised of three generations:  Boomers (1946-64), Xers (1965-80) and Millennials (1981-99), each generation with its own unique set of characteristics.  The American Association of Orthodontists (AAO) now reports that more than 51% of its membership is composed of Gen Xers and Millennials.  By virtue of their birth timing Xers and Millennials, including myself (1966), were the first generations to grow up with computers in their homes.  Although Gen Xers differ from Millennials in many ways, technology is now ingrained into nearly every part of both generations’ lives.  For those Xers and Millenials that also happen to be orthodontists, this attachment to technology includes not only their personal lives, but also their orthodontic practices.

Over the last few years, my blog posts have centered on the discussion of a “Digital Orthodontic Practice.”  A digital practice must include not only the management and record keeping aspects (paperless) of our offices, but also clinical diagnosis and tooth alignment functions.  In this post, I want to highlight the current opportunities for moving digital in the clinical portion of your practice.

Diagnosis:

The clinical care for most orthodontic patients begins with a diagnosis and a treatment plan.  Given that Kodak is now only a shell of the company that it once was, I think it is safe to say most orthodontic practices are now taking digital photographs, instead of film, as part of their diagnostic records.  The recent 2014 JCO study of Orthodontic Diagnosis and Treatment Procedures1 found that more than 91% of the respondents used digital radiography, 69% used CBCT either routinely or occasionally, 41% used digital models and 28% used intraoral digital scanners.  Additionally,  the American Board of Orthodontics (ABO) recently announced that all initial models for their exam must be submitted in a digital format.  While the JCO survey included a relatively low number of respondents (n=135), I believe the findings are indicative of the Electronic Health Record (EHR) movement in all of the health care profession.  This movement, aided by government mandates and subsidies, has now breached the threshold level.  The train has left the station.  If you and your practice intend to stay relevant over the next decade, you absolutely need to be utilizing digital diagnostic records.

Tooth Alignment:

As our profession transitions to a digital diagnostic record norm, some are looking to move beyond diagnosis to digitally construct tooth aligning appliances.  In 1999, Align Technology opened the door to digital orthodontic tooth alignment with the introduction of the Invisalign system.  The system at that time relied upon traditional dental impressions, but today intraoral scanners and 3D printing have allowed for the elimination of the impression procedure.  Whether it be Align, or any other current Clear Aligner option, a digital model (.STL) of a patient’s dentition can be captured with a scanner, the teeth can be aligned using computer software, and treatment appliances (clear aligners) can be fabricated by machines based off of the digital “plan”.  Furthermore, this process can now also be utilized for patients using traditional bonded brackets.  Custom brackets along with custom bracket placement jigs and custom wires digitally planned and robotically bent are possible.  In large part because of costs and the learning curve, the digitization of clinical orthodontic procedures has not yet been completely accepted.   However, as the techniques become more refined, we should expect the cost to include them into our practices to decrease and implementation by the tech savvy Xers and Millennials to accelerate.  If you are an Xer or a Millennial, and have not already incorporated digital tooth alignment into your practice, you should be planning to do so in the near future.  If you are a Boomer, and potentially less comfortable with technology, you need to consider if you can afford to ignore this change.

Creating an esthetically pleasing and stable smile, can be a bit like designing and constructing a building.  In a recent conversation with a Boomer architect friend of mine he described the digital changes his profession has undergone.  My friend reported that my office, built in the year 2000, was one of the last buildings he drew by hand.  All of his projects now are digitally designed using 3D CAD technology, allowing him to plan and visualize the end construction result more effectively.  The transition in the architectural profession took time and learning.  Change is never easy.  However, as my friend now approaches the end of his career, he finds the “old” way inefficient and less accurate.   Whatever generation you were been born into, I encourage you to embrace the digital change our profession is in the midst of.  I am certain a digital orthodontics will ultimately benefit you and your patients.

1Keim Et.Al. 2014 JCO Study of Orthodontic Diagnosis and Treatment Procedures, Part 1: Results and Trends Journal of Clinical Orthodontics 2014; 48:10 pages 607-630.