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.

Google+ vs Google My Business

3872b46By Dr. Greg Jorgensen
Rio Rancho, NM

There is no question that the Google search engine is THE search engine of choice in today’s online world. When you want to find something on the web, you “Google” it. The most current statistics estimate that 90% of all online searchers used Google in 2014. Yahoo and Bing each attracted about 3% and the remaining 4% was divided up between several less widely accepted search engines. Google is king and if you want your orthodontic practice to be found, you must focus your SEO efforts on being optimized for Google.

Google has two other services that bear the Google name but may be less understood by orthodontists. Those two are Google+ and Google My Business. One is VERY important to every business and the other may not be around a year from now. Let’s take a look.

Google+ is Google’s version of Facebook. Like Facebook, you can post photos, statuses, and videos. Acquaintances are grouped into Circles which represent groups of people with something in common. Their version of the Timeline is “The Stream.” Google+ has a useful communication feature called Hangouts which allows group texts and video chats. Over 500 million users are registered on Google+ (compared to Facebook’s 1.3 billion), but the average interaction is only about 7 minutes per month. Its biggest strength is its tight integration with Gmail and YouTube which are very popular online services. Because it is so similar to Facebook without offering any real advantage, many on the “inside” feel that like several other Google attempts at a social network, Google+ is on its way out.

Google My Business is Google’s version of a Facebook business page. (It has formerly been named Google Places and Google+ Local.) Like a Facebook business page, there are pictures, a description of the business, hours, form of payment, a map, and reviews. A Google My Business listing is like a full page ad in the yellow pages in years past, and it is completely free. The one big advantage that Google My Business has over a Facebook page is that this listing is presented as the primary search result whenever someone performs a local search for an orthodontic practice in your area. The types of keywords that make a search local include business names, zip codes, addresses, phone numbers, and neighborhood names. Although patients may be able to search for your business within Facebook, most will just Google your name and find your Google My Business page.

In the interest of time and return on investment (ROI), which if either of these platforms is important for orthodontists? First and foremost, you MUST have a listing on Google My Business. When someone searches for an orthodontist in your community, Google will look first for your Google My Business presence. It must be complete, accurate, and attractive. Next, you should concentrate your social network efforts primarily on your Facebook business page. Zig Ziglar said, “Fish where the fish are.” The fish are on Facebook. There are conflicting opinions on the value of Google+ for an orthodontic office. The service is owned by Google and we all want to “stay in their good graces.” As for ROI, however, I personally haven’t seen any at all.

Virtual Setups Using Intra Oral Scanners for Same Day Consultation

IOScan_exampleBy John White DDS, MSD, ABO

Having been in orthodontic practice for 35 years, I’ve seen a lot of changes in all aspects of orthodontic care.  Most changes have been totally under our control and are merely choices. Whether you choose to use self-ligating appliances or not impacts your mechanics but not really your ability to produce an excellent result. Most cases do not require a CBCT to adequately diagnosis or treatment plan to achieve that same excellent result. Robotic orthodontics, also known as pre-bent appliances, have benefits and drawbacks, but once again are unnecessary for creating that “perfect smile”. Most of us have never done more than dabble in lingual appliances; without any loss to our practice. And while clear aligner therapy has probably the greatest (potential) impact on the traditional delivery of orthodontic care, there are plenty of very successful orthodontic practices that presently don’t use it at all or only on a limited basis.

That being said, competition in the market place has changed significantly, from the outside. We can’t rely on the “gold plated” referrals from our GP colleagues like we once did. Second opinions are becoming the norm. We have one chance to develop a relationship while we present our treatment “design”.  We deal less with patients and more often with consumers.  Where we used to do exam / records / consultation on separate visits, the sequence has evolved for many of us into a single visit. We used to show our beautifully finished cases with plaster models and photos, or cut and pasted smiles from the AAO smile library and so forth. Today’s consumers want more.

The advent of CAD/CAM treatment planning and design software is changing all that.  We now have the ability (and even possibly the responsibility) to do virtual treatment planning, trying out options and alternatives with accuracy and predictability. The ability to customize everything about treatment from the beginning goes beyond the capability to modify and adapt the otherwise generic prescriptions and archforms of the past to match the particular patient’s needs.

Tens of thousands of patients have seen their clear aligner predictions or pre-bent setups. This is changing the exam and consultation process. Patients are becoming aware that we can show them what their teeth will look like post treatment. An interactive approach to smile design and occlusion function is not only possible but a significant advance in marketing and patient appreciation of what goes into their treatment plan beyond just straight teeth.

For purists, one of the leaders in CBCT scanners is currently beta testing 3D integration of IO scans with CBCT imaging and computerized jaw tracking.

There are stand-alone software that permits visualization and treatment planning of IO scanned data, and some IO scanners come bundled with similar software.  Some scanners are not only able to directly scan to aligner companies, but also come bundled with “Treatment Simulator” software.

While I am invested primarily in a single technology, I routinely use several of these and am doing trial runs of others. The learning curve is not terribly steep for any of these. And they all work.

The logistics of same day exams with IO scan and treatment simulation becomes the biggest hurdle.  We do an office tour ending with a CBCT (with face scan) and photos, if the IO scanner is available and the patient has time, we do an IO scan. This combination takes 30-40 minutes (as opposed to 20-25 without IO scan). While we review CC and get acquainted, everything is loaded.  The treatment simulation is run in the background (the 3 treatment algorithm choices are preselected).

After we have reviewed my diagnosis we look at the treatment simulation and start moving teeth to reflect my recommendations and patient wishes.  This not only increases patient engagement but shows that I am intimately involved in the treatment design, not just letting the computer treatment plan for me. It helps explain tooth size discrepancies and why IPR may be necessary (even on extraction cases). We can measure expansion and torque requirements and cuspid inclination. And it is especially useful for pre-restorative setups; visualizing spacing and vertical setup, bonding undersize laterals, etc.. Multiple treatment scenarios can be done to help illustrate trade-offs in compromise cases.

Not only is there improved communication with and education of the patient/parent, but a unique understanding of the case above and beyond the “Old Days” where I fondled a set of soaped and polished study models or CR mounted models.

Finally, we can re-establish our reputation with consumers as the experts in orthodontics by using and properly explaining to them the benefits of this technology.