Dentistry is rapidly changing and staying the same, all before our eyes. As dentists, we have a responsibility to stay at or above the standard of care for our community. As new procedures and technologies enter the marketplace, how do we decide when to add them to the practice and when do we stick with the tried and true? It is not an easy question and there are numerous answers.
New technology can make our jobs easier. New impression materials have made obtaining accurate, flavorless, quick impressions an easy procedure. Digital radiographs allow us to expand the size of a picture and enhance it with the touch of a key. Computer-aided design and computer-aided manufacturing (CAD/CAM) systems allow for generating impressionless models and crowns in one hour. But making our job easier should be only one part of assessing the value of a new technology.
A second and equally important question is will it be more comfortable for the patient? The answer is easy for impression materials. The horrible, smelly materials of the past and the potential errors that accompanied its use are history. Combine that with trays that now fit and setting times that are comfortably fast and it is easy to see what benefit we are offering the patient. Patient comfort with other technologies is less clear. Digital radiographs are great and the reduction in radiation is a godsend, but the tabs are stiff and difficult for some patients to tolerate. CAD/CAM systems allow for fabricating crowns in 1 hour but require using a precise technique, and patient wait times in the office that may not fit the patients’ needs.
A final question that must be answered is will the new technology improve the quality of care? There are a lot of potential solutions to issues that we face in dentistry, but often the solution only works if the practice is willing to lower its standards of care. Early renditions of the in-office ceramic crown manufacturing systems depended on superior preparation technique, lots of cement, or both. In a field in which we use nanometers for the space between tooth and crown, the early in-office crowns could not compete with beautiful laboratory made crowns unless the quality was compromised. Composites have continued to improve on almost a daily basis, but they still do not compare in longevity and resistance to wear what we see in amalgams. And they do not compete at all if they are placed like amalgams. Composites require a much drier environment and multiple layers if they are to fit without voids and have the strength to resist biting pressure.
These three questions. Does it improve the ease of care? Does it make the patient more comfortable? And does it improve quality? Are all essential when evaluating new technologies? Of course, the overriding question then arises: how do we evaluate new technologies while sitting chairside in our practice? For some, it is simply a matter of buying the product and using it. If it does not work on enough patients, stop using it. Many dentists use this technique. I would recommend that you find dentists who use this technique and befriend them. They will show you the products that are now gathering dust in their office closet. The caveat here is that many of us, to justify having already spent our money, will develop rationales for why the technology benefits us. Often the rationale is centered around money. A laser has a few important uses. Some periodontists are finding excellent results from its use. General dentists are a little less likely to find all three questions answered when they consider purchasing a laser. However, they might use it to start filling dark spots on molar crevices that they have been looking at for ages. They might find it necessary to charge for gingivectomies around crown preparations. And they might want to offer periodontal recontouring to patients with gummy smiles. A laser could then pay for itself, but consider thoughtfully any nonmonetary cost to the standard of care?
CAD/CAM is another huge change in the technology of fixed restorations. It can save the whole laboratory bill if all the crowns are done in house. But if all the crowns are done in house, are they at the same quality of the laboratory made crowns? The chairside fabrication system costs a lot, but can save a lot, if used a lot. Again, if used exclusively, does it maintain the quality of care that the practice provided before it was purchased?
One last area of exploding technology for which the three questions need to be asked is implants. In the early years of implants, only a few dentists who provided them seemed to have success. The rest of the profession found them impossible. Today, implants are a wonderful addition to the options available for patients. They do not improve the ease of care however. They are more expensive and take much longer than a bridge or partial denture. They certainly can make the patient more comfortable; dentures fit more securely, individual crowns are much easier to maintain, and often the appearance is much better than a bridge pontic. Do they improve quality? They certainly keep the dentist from preparing otherwise healthy teeth for bridgework. And they are easier to clean than a bridge or partial. But are they a quality improvement over a root canal or periodontal surgery to save an existing tooth? There is a lot of debate in that area. Should we save a compromised tooth or extract it and place an implant? A good answer to the question is what would I do for myself in that instance? If you would extract your dying tooth and replace with an implant or have a bridge placed rather than undergoing the two surgeries for an implant, it can help you give similar advice to your patients.
New technologies will continue to improve and confuse the profession. By relying on the three important questions and maintaining a high level of ethics and quality, we will continue to be the professionals our patients assume us to be. And we will be able to guide them toward the best dental care in the world.
Dr. van Dyk practices general dentistry in San Pablo, California, and teaches in the department of Dental Practice at the Arthur A. Dugoni School of Dentistry. He lectures throughout the US and Canada and is happy to expand on his message of surprising patient management. He can be reached at firstname.lastname@example.org or at vandykcastro.com.