May 1, 2010
by Kenneth S. Serota, DDS, MMSc, Frederic Barnett, DMD, Cert Endo (D)
While innovations from the technology industry have fashioned ever more sophisticated equipment for dental use, it is essential that the profession reflect upon whether these advances have actually improved the standard of care in dental practice. The dominant trend in any industry is to use technology as an instrument for enhancing productivity; dentistry has followed suit. Features and benefits of “big ticket” equipment purchases are marketed with strategies for per diem aggregate usage to ensure payout of amortization schedules and return on investment within the shortest possible timeframe. The science providing evidence of the therapeutic value of the item is far too often provided by circumspect studies and primary investigators with fiduciary relationships to the manufacturer or distributing companies. If this construct persists, the increased use of technology for the wrong reasons will threaten the dentist/patient relationship and the profession itself. Dentistry cannot allow itself to be subverted to a “boiler room” mentality wherein therapeutics is a function of commerce, not standard of care in diagnosis and treatment planning.
The costs of any technology are not limited to just the price of the equipment itself. Each technology purchase must be integrated into a hardware, software and human network. This mandates upgrades, updates, expanded storage capacity and most importantly, constant training as well as the means to deliver digital and print media records for legal documentation and patient education. Technology is reinventing the world and dentists need to keep pace with the people they serve by raising the bar for the standard of care in their expanding service mix. The availability of many different treatment choices and access to information has empowered our patients. Regardless of our bias or perceptions, they want to be informed and involved in the decision making process regarding their treatment plans. Instructive technology must be partnered with diagnostic and therapeutic technology. It is a patient’s right to receive this at the highest possible level.
The goal of evidence-based dentistry is to amalgamate sound research evidence with experiential clinical expertise and patient values to determine the best course of treatment. The implementation of this integration is proving to be more complex than anticipated due to a virtual “information explosion” on new therapies, techniques, and materials, increased consumer understanding of treatment possibilities and therapeutic outcomes as well as changing socio-demographic patterns. For example, the detection, diagnosis and monitoring of the most elemental aspect of dental disease, incipient caries lesions, is within the technologic province of laser fluorescence [the DIAGNODent laser], quantitative light-induced fluorescence and the DIFOTI system [Digital Imaging Fiber-OpticTransillumination]. We’re a long way from “a couple of bite-wings”.
The responsibility for correctly combining the various pieces of digitized information into a treatment plan that satisfies the patient’s personal preferences, attends to socio-behavioural aspects and takes care of the patient’s biomedical needs will continue to rest with the clinician, not the computer. This science of dental informatics has been well defined by Schleyer and Spallek. It is expansively multivariate as dentistry is increasingly an information-intensive activity. The growth of dental informatics is hampered, in part, because many of its benefits are hard to measure and achieving them requires significant upfront and ongoing investments. You can appreciate how there is a “ring around the rosy” aspect to new technologies or as Aristotle so eloquently stated – circular reasoning occurs when an inference is drawn from a premise that includes the conclusion. There is one area in dentistry however, where the impact of technology and its value is irrefutable and that is the diagnostic potential of cone beam volumetric or computed tomography (cbVT or cbCT) or in its most elemental description – three dimensional radiography, without the “funky” glasses.
The most magnificent edifice clad in limestone or marble quarried from Carrara, Penteli or Trani still requires a determination of the location of water, sewage, gas and electric conduits before its foundations are excavated. Mechanical engineering, which began in the Islamic golden age during the years of the 7th to 15th century, is essential to ascertain that the environmental forces of nature’s ecosystem will not exceed the static or dynamic continuum mechanics that allow an edifice to stand. Does the accrual of three-dimensional diagnostic information for comprehensive care and treatment planning require any less a level of sophisticated analysis and biomechanical understanding to exist in the oro-facial ecosystem. The authors will attempt to answer this in their article on cbCT in this journal. Websites of relevance to this editorial and article can be viewed at www.rxdentistry.com/barnett and www.endoimplantalgorithm.blogspot.com OH
Dr. Serota graduated from the University of Toronto, Faculty of Dentistry in 1973 and was awarded the George W. Switzer Memorial Key for excellence in Prosthodontics. He received his Certificate in Endodontics and Master of Medical Sciences Degree from the Harvard-Forsyth Dental Center in Boston, MA.
He was selected for Fellowship in the Pierre Fauchard Academy and is a Fellow of the Academy of Dentistry International. The founder of ROOTS – an online educational forum for dentists from around the world who wish to learn cutting edge endodontic therapy, he has recently created blogs at www.endoimplantalgorithm.blogspot.com and www.ankylosforum.com in order to provide a clear understanding of the endodontic/implant algorithm in foundational dentistry. As well, he lectures on the empowerment digital technologies provide to the sophistication of the dental team and the propagation of comprehensive care.
Dr. Barnett received his DMD degree in 1978 and his Certificate in Endodontics in 1981, both from the University of Pennsylvania, School of Dental Medicine. He received his Board Certification in Endodontics in 1986, has served as the Director of Postdoctoral Endodontics at the University of Pennsylvania, and is currently the Vice-Chairman of Dental Medicine and Chairman and Program Director of the Postdoctoral Endodontics at Albert Einstein Medical Center in Philadelphia.
Dr. Barnett has written numerous scientific and clinical papers and has lectured nationally and internationally on the Treatment of Endodontic Infections, Dental Trauma and Contemporary Endodontic Treatment. Dr. Barnett has also been in private practice in Endodontics since 1981.
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