The evolution of the modern dental practice over the past decade has been nothing short of incredible. Many offices are now completely paperless or, at the very least, have eliminated the need for a physical paper chart. Digital systems continue to replace older analog systems, resulting in increased efficiency for the practice. As patients are viewed more and more as consumers, it is vital for every practice to not only be current with their technology, but to take a realistic look at how that technology can improve the practice, either from the patient's viewpoint or the practice's bottom-line.

Although there are many technologies that are being incorporated into dental practices, there are currently four, in my opinion, that have received the most press recently. These are Digital Radiography, Soft- Tissue Lasers, Hard-Tissue Lasers, and the newest craze-Cone Beam or 3-D Imaging. The purpose of this article is to review the benefits of each of these technologies, how to best use the systems to increase the practice's profitability, and to determine if the you can justify the high cost of some of these systems through a positive return on the investment.

Digital Radiography

Although not a "new" technology-if you consider that the first systems were introduced in the late 1980s-the adoption of this technology has just started to take off in the past 5-7 years. When we talk about digital radiography, it's important to distinguish between the three different methods of obtaining digital images:

1. Hard Sensors-These are the systems that most offices are familiar with. It involves a CCD or CMOS sensor that is analogous in size to a film, attached by a cable to a small box that is connected, usually via a USB cable, to the computer. Images that are taken with a hard sensor appear on the screen in about 4-5 seconds after capture. These sensors require imaging software that can recognize the sensors.

2. Phosphor Plate Systems-Often described as a cross between film and digital, these systems retain much of the familiarity of film but also some of the advantages of digital. Images are captured on thin, wireless plates that are equal in size to their film counterparts. These plates are then taken to a central unit where they are scanned into the software, "mounted", and then made available for viewing on any other computer.

3. Transparency Adapter-Although not digital in the true sense of the word, many offices still have film in their charts or film patients bring from other offices that they would like to incorporate into the digital record. To accomplish this, you will need a special film scanner that has a large transparency adapter. Once the X-rays are digitized, they can be viewed and enhanced just like any images taken from hard sensors or phosphor plates.

Obviously, the choice of which type of system to get (and some offices get all of them) will depend on numerous factors. For example, a practice that does a lot of endo or implants would do better with hard sensors as the time to see images on the screen is quite a bit faster than the other methods. Conversely, a large practice with many operatories may lean toward a phosphor plate system as the costs to outfit multiple rooms with sensors may be prohibitive.

The first and most important decision, however, should be that the practice needs to determine if adding digital radiography will have a positive return on investment. For almost every office, the answer to this is YES! There are many reasons why digital radiography should have such a positive effect on the bottom line:

A. The time savings, especially with hard sensors, is substantial. The average office I've worked with can do an entire FMX of intraoral X-rays in less than 8 minutes. For many offices, they can easily schedule one to two extra appointments per hygienist each day due to the time savings.

B. Being digital will present the office as being "high tech." This will attract new patients and result in more referrals from existing patients. Since digital X-rays require less radiation than traditional film, the practice can use this information in their internal an external marketing.

C. Elimination of all the items normally needed for film X-rays, such as film, chemicals, and processor maintenance, will save the practice money in the long run.

D. Most digital radiography users find the systems to be more diagnostic than film, so if the dentist can now find pathology that they couldn't see before, it should translate into higher revenues as more procedures will be performed.

Although the initial costs for adding digital radiography are significant, there's little doubt that practices that use the technology and market the service to their patients should find it to be one of the best investments they ever make for the practice.

Lasers

Although digital radiography is now experiencing the explosive growth that intraoral cameras enjoyed back in the 1990s, lasers are still at less than 10% market penetration. However, it is my opinion that the next major technology to gain wide acceptance in dentistry will be lasers, so dentists should be aware of what these systems can do and how they can benefit the practice.

Part of the reason that dentists will need to consider lasers is that our patients are becoming more selective in the procedures they want. The main focus of any practice is to provide our patients with the treatment and care that they obviously need. However, in 2007, many of our patients consider themselves to also be consumers. Meaning, it may not be enough to give them what they need, but also what they want at the same time. If you speak with any of the well-known practice-management consultants like Sally McKenzie, they will all tell you the same thing: from a marketing standpoint, it's far more effective to market to your existing patients than it is to try to bring new patients to the practice. To accomplish this, we need to give the patients what they want. How do we know what that is? Easy.they've been telling us that for years. Patients want procedures that are "less." Specifically, they want treatment that is painless, needleless, without drilling, and bloodless. Thankfully, lasers meet all of these criteria.

As with any modern technology, it's not necessarily the ideal product for every dentist out there. In working with offices all over North America, I've identified what I consider to be the four main types of candidates for soft- tissue lasers:
1. Dentists interested in patient comfort and conservative care. One of the catchphrases that have become popular lately is the concept of "minimally invasive dentistry." Many dentists want to do the least amount of damage, remove as little tissue as possible, and make the procedure comfortable for their patients. These offices would be great candidates for soft-tissue lasers. These devices are certainly geared toward conservative care. Used properly, soft-tissue lasers will cause little to no discomfort; more than 50% of procedures are done without local anesthesia according to one survey.

2. Quality of treatment. Dentists are always looking for a better "mousetrap," a way to do the old procedures more effectively. Although there are many good selling points to the soft-tissue lasers, a key factor is the fact that with a laser, the dentist can be more accurate, more precise, and have a more predictable outcome from the procedure. Lasers allow for an extremely fine amount of detail and precision, more than you would be able to achieve with a #15 scalpel blade.

3. Efficiency. Many dental procedures involve a lot of wasted time. For example, if a dentist does a crown preparation that extends subgingivally, they will often need to wait at least 15-30 minutes to achieve hemostasis before they can take their impression. Imagine how more efficient the office could be if they could immediately stop the bleeding and have a dry field. This would cut down on the chair time needed and allow the practice to see more patients during the day.

4. Finally-and this is part of the efficiency model-the ability of the practice to become more profitable. Not only will there be increased efficiency, but there should be more soft-tissue procedures being done. This is the result of the practice actively marketing their use of the soft- tissue laser. The practice will see an increase in the number of new patients coming to the practice for treatment. Just as importantly, the dentist will develop the confidence to perform minor soft-tissue procedures that used to be referred to other specialists. Most of the procedures done by soft-tissue lasers are relatively easy to learn. Note: receiving proper training from the laser manufacturer is something that I highly recommend. Most vendors include this training at no additional charge with the purchase of their systems. And, even if they do not, there are many organizations such as the Academy of Laser Dentistry and the Las Vegas Institute that offer training.

Obviously, there are differences between hard- and soft-tissue lasers. Basically, any soft-tissue procedure that a dentist can think of can most likely be done with a soft-tissue laser. Some of the most commonly performed procedures include: sulcular debridement, frenectomies, soft- tissue crown lengthening, biopsies, fibroma removals, incision and drainage, second-stage implant uncovering, removal of moles and hemangiomas, removal of hyperplastic tissue, uncovering of unerupted teeth for orthodontics, and treatment of herpetic lesions and aphthous ulcers. Some offices are even using soft-tissue lasers during endodontic therapy for debridement of the canals. If you can think of a procedure that has been done in the past with a scalpel blade or electrosurgery unit, then you've thought of an excellent use for the soft-tissue laser.

On the hard-tissue front, the more common procedures are Class I, II, II, IV, and V cavity preparation, hard-tissue roughening or etching, osseous clinical crown lengthening, apicoectomies, root canal preparation-including enlargement and debridement and cleaning-caries removal, enameloplasty, excavation of fits and fissures for sealants, ostectomy, tooth preparation for access for root canals, preparation of root ends for retrofill restorations, osteoplasty and recountouring, cutting bone to access roots for treatment..the list goes on and on.

When it comes to how best to utilize the technology, a recent survey done in one of the dental journals gave a lot of insight into how dentists can maximize the use of lasers in their practices:

• More than (54%) of dentists use their lasers without any anesthesia for the majority of the soft tissue procedures they perform.
• The top soft-tissue procedures being done by dentists were incisional and excisional surgery, cosmetic gingival recontouring, noncontact procedures (such as treatment of aphthous ulcers and hemostasis), and sulcular redevelopment (troughing) after restoration preparation. When they asked dentists why they had decided to purchase a laser, the main reasons given were to improve their ability to perform procedures already being offered by the practice, to expand the scope of procedures they could provide, to attract new patients, and to increase the practice's profitability.
• 50% of the respondents were seeing a minimum of 3-5 new patients per month that they could attribute to their use of the laser.

With proper training and marketing, any practice can see immediate and measureable results by adding laser technology to the practice.

3-D Imaging

The latest and greatest addition to the dentist's arsenal is now 3-D imaging. It goes by various names, such as Cone Beam Volumetric Imaging, Cone Beam Volumetric Tomography, or Cone Beam Computed Tomography. The goal of 3-D Imaging is to produce immediate three-dimensional images of patients' critical anatomy, typically in less than 40 seconds. The machine provides complete views of all oral and maxillofacial structures in an easy to use, cost effective, in-office system that allows dental specialists to dramatically enhance their patient care in a variety of ways. By producing a three dimensional reproduction of the patient's face, jaws, and mouth, it can improve the relationship between the dentist and patient by providing necessary information to the patient to make informed decisions about their treatment. These devices are also more than capable of producing more standard imaging such as pans and cephs for offices that don't require the higher level of information found in the 3-D images.

Although there are a number of indications for Cone Beam technology, the main applications are:

• Location of the mandibular nerve and sinuses
• Evaluation of trauma
• Viewing the TMJ
• Evaluation of impacted teeth
• Creation of surgical guides
• Assessment of locations for implants
• Evaluation of odontogenic lesions
• 3-D modeling

Although any dentist can benefit from the features of a Cone Beam system, the software of most of the systems is geared toward periodontists, oral surgeons, and orthodontists. It's difficult to determine the return on investment of these devices as they are so new to dentistry. At $160,000-$250,000 each, they are currently out of the price range of most solo practitioners. However, I have seen many "Imaging Centers" being established around the country where multiple practitioners will pool their resources to purchase the systems and offer imaging services to other practitioners in the area.

The modern dental practice continues to evolve at a very rapid pace. Many analog and paper-based systems are being replaced by digital systems that can increase efficiency, provide a higher level of diagnosis and treatment, and meet the needs and desires of our patients. Any of the technologies mentioned in this article would be a great asset to most dentists. Practices should take the time to evaluate each system's capacity to provide better treatment options while also considering how to use the systems to benefit their businesses.