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The future of digital dentistry in Implantology
Interview with Professor Daniel Wismeijer
Daniel Wismeijer graduated in dentistry from the University of Nijmegen Dental School, The Netherlands. He received his PhD in 1996 on the subject of overdentures on dental implants. From 1985-2006, he worked at the Department of Oral Surgery and Maxillofacial Prosthodontics at the Amphia Teaching Hospital in Breda, Netherlands. Since 2006, he has held the position of Professor of Oral Implantology and Prosthetic Dentistry at the Academic Centre for Dentistry in Amsterdam (ACTA) which he combines with his referral practice. The main research areas in his department are focused on CADCAM treatment optimization, implant surface and bone substitute optimization, and evaluation of different implant-based treatment modalities. He has run a dental practice since 1985, with specialization in Implantology since 1990.
What would be your own definition of “digital dentistry”?
Up to now, dentistry was mostly carried out in the “analogue” world: we examined X-rays on film, patient information was recorded on paper, models were waxed and analogue articulators were used. The stage we are in right now is that certain steps of the process are done digitally, but they are still “digital islands” in an analogue world. For example: parts of the treatment planning are carried out digitally in the virtual environment but the drill guide is still analogue. Or we design the prosthetic model on a CAD station, but still need a physical model via rapid prototyping to test the fit of the crown. This results in numerous switches from analogue to digital and back. In my view, digital dentistry is developing to a world where patient and in-mouth product (bridge, crown, etc.) are analogue, but everything in between becomes digital. Digital dentistry is like a bullet train coming at us and its impact will be significant. Think of the changes in the photography industry when it went from analogue to digital. Companies such as Kodak and Agfa are still trying to recover from those changes. Something similar will happen to dental.
What will be the benefits for the patient that will result from digitalization?
Impression-taking will be replaced by intra-oral (IO) scanning. This will be more comfortable, quicker, be reversible, with less chairtime and, as a result, less costs. If we can fully digitize patient treatment, we will be able to reduce the number of visits significantly. Furthermore, analogue intermediate products require a switch from digital to analogue and back from analogue to digital. This causes loss of precision. For example, impression material shrinks or expands. Pouring plaster which often hardens due to an exothermic reaction causes another deformation of the impression. Waxing and metal casting cause further imprecision.
If we can stay in the digital world, we will have two advantages: first, we can prevent this loss of precision and secondly, if a mistake is made in the digital world, you can always go back to the previous step or the digital model you had before the error was made. This implies benefits for our patients. A vivid example of early defect detection is the ability of software to tell whether an IO scan is usable – when the patient is still in the chair. You will not need to wait for a call from the lab informing the dentist that the patient needs to return because the cast poured from the impression turned out to be unusable or was not of the expected precision. Another example: a fit test of the coping performed by the software before the porcelain is baked on it. Baking porcelain leads to about ten percent shrinkage and shape alteration. Putting the porcelain on the coping is half the cost of the crown. Fitting first digitally before the porcelain is added makes a lot of sense, especially if it is a multi-unit structure where one failure can cause the whole structure to fail. And if we could achieve a digitally induced 100% fit it would also extend the lifespan of the product.
What will be the impact of digital dentistry on the practice of surgeons and general practitioners?
Let me start with my own experience as a dental practice owner: I use more and more software systems and, as a result, am confronted with steadily increasing IT costs. And this is not yet all. Many practices have or will get CBCT scanners, IO scanners, digital scanners, colour scanners and patient management systems.
What dentists need in such an environment is a safe communication platform with referring dentists, patients, insurance companies, suppliers and milling centres. This is not available yet. I have even proposed putting my IT consultant to get on my payroll because I need his services more and more and having him on standby on a salary may be cheaper!
And what does the dentist receive in return for these investments in hardware, software and consulting services?
Dealing with costs is one of the problematic aspects of the continual digitalization of procedures once analogue. Going digital, on the other hand, provides clear benefits to the dental practice: many of the current intermediate products result in waste. In a country like the Netherlands, plaster is considered as toxic waste. My faculty will be able to reduce costs significantly because the amount of toxic waste is reduced when education is more and more digitized. Of course there is a trade-off: we will need more computers and software and the investments in networks will increase. But making a quantitative trade-off is not that easy because we are not able to make a quantitative cost/benefit analysis across the value chain. Today, the dentist, the lab and the surgeon may each do their cost analysis, but the total saving for the three combined cannot be calculated. If you offset the costs for dental computer equipment off against the maintenance of these machines and the cost savings generated you can calculate the saving. The dentist has to learn where exactly in the dental value chain improvements have to be made in order to optimize the use and the benefit of digital tools.
Do you think that it will be possible in the future to practise dentistry without digital support?
Maybe in the short term – but in the long term, dental professionals will have to rely on digital dentistry technology. As for every new technology, there are the early adopters but the time for the others to get on board will be scarce. This also applies to the dental technicians who will have to be trained in information technology. They will need to stay ahead of dentists in the field of CADCAM design and acquire new skills. If they do not, there will be little work left for them.
