The Role of High Technology in Maintaining Esthetic Restorations
by Ronald E. Goldstein, DDS and Marilyn C. Miller DDS, FAGD 
 
Journal of Esthetic Dentistry Volume 8, Number 1

Page 2 of 3

COMPUTER IMAGING
Before any treatment has begun, esthetic or computer imaging has made it possible to graphically display how patients can appear after esthetic correction. It takes the intraoral camera one step further, from chronicling the current condition to giving patients a look into possible future outcomes.

Generally, imaging systems consist of a computer, video camera, " frame grabber" (imaging board), graphics tablet, monitor, and printer. Since images consume a large amount of computer memory, often a gigabyte-size hard drive or an optical disk is necessary. Software for these systems varies with manufacturers, each with its own advantages and disadvantages. System selection is usually based on individual preferences.

Most systems allow for image modification of almost any esthetic procedure. Examples include closing diastemas, bleaching or veneering teeth, altering tooth form, or showing the patient the results of orthodontic treatment. Changes that are represented to the patient must be realistic, and it must be emphasized that the image is a goal, not an exact replication of treatment results.

Besides alleviating a patient's apprehension about proposed treatments, imaging technology has many other uses. Patients who grind their teeth should be imaged and the proposed esthetic correction shown following cosmetic contouring or reshaping of the natural teeth. These images can be compared in the future to see if the patient is continuing the habit that caused the problem. Although a nightguard appliance can often be fabricated to control the problem, imaging can demonstrate whether or not the patient is actually wearing it. The best evidence that it is not being worn may well be imaging of the patient at a later time. This permits the patient to serve as "co-diagnostician," which helps ensure that the patient will not only be pleased with the results, but will also play a greater role in maintaining those results.

Another use of esthetic imaging is to show patients the effects of their failure to maintain their new esthetic restorations (Figure 6). A verbal warning usually is ignored. A photograph or illustration can go a long way in helping the patient visualize what can happen. However, nothing communicates more effectively than showing a patient images of his or her own mouth to illustrate the potential destruction that can result from bad habits.

The longevity of esthetic restorations depends on the maintenance of the soft tissues and bordering supporting structures. Computerized charting systems enhance the capabilities of the dental team to detect changes in the periodontium by facilitating the collection and storage of periodontal diagnostic data, producing comprehensive graphic and numeric charts, and enabling dental professionals to easily track the dental condition of patients. At the most basic level, information about the periodontium, such as pocket depth, bleeding, and plaque scores, can be entered manually into the computer. Although having to collect the information by hand and enter it into the computer is still labor intensive, available software allows for fast and accurate comparisons of data not possible with a totally manual system. Voice-activated systems, thus, save time by eliminating double data entry, while maintaining the chain of infection control.

With this technology, the computer is able to recognize a limited, though sufficient, vocabulary to complete a periodontal examination. The more sophisticated systems are preprogrammed to recognize a wider speech pattern range and can be used by multiple practitioners who speak with different dialects. One commercially available example is the Victor Voice Chart (Pro-Dentec, Batesville, Arkansas) (Figure 7). The user wears a lightweight microphone headset connected to a computer that records information about the patient during an examination.

This permits the practitioner to examine the patient and enter data simultaneously without either an assistant or the need to touch a pencil or computer keyboard.
The easy-to-read graphic charts produced from these systems enhance patient education and understanding. Using these charts, the dentist can readily point out changes that have occurred between examinations and more simply explain the need for additional treatment or preventive regimens. Patients who understand clearly the current condition of their mouths may be more receptive to these recommendations and more motivated to follow through with home care instructions.

Electronic periodontal probing systems, which are essentially semi-automated, make use of an optical encoder to scan and record pocket depth. These systems not only measure pocket depth, but also record supplemental periodontal examination information, such as gingival bleeding, tooth mobility, plaque scores, and furcation involvement. To measure pocket depth, the practitioner directs the probe to touch a predetermined anatomic landmark on the tooth or tissue. The computer then measures the distance from the base of the pocket to that landmark, and the measurement is recorded using a foot pedal. Since the same relative landmark is used at each site during all examinations, comparisons can be made of measurements from area to area within the mouth. This information can be displayed on a computer screen, printed out, or stored for future comparisons.
In addition to facilitating charting and storage of patient information, new computerized diagnostic devices provide adjunctive tools to identify pathologies that may interfere with the preservation of esthetic restorations. The PerioTemp (Abiodent, Danvers, Massachusetts) records pocket temperature of a specific tooth and determines whether it is at, near, or above the temperature of a comparable, normal, healthy one. The Periotest (BioResearch, Milwaukee, Wisconsin) provides objective data about tooth mobility and implant stability by determining the deceleration of a force applied to a tooth or implant. This deceleration is proportional to mobility and the amount of periodontal support or osseointegration. Another diagnostic device, T-Scan (Tekscan, Boston, Massachusetts), records the timing, location, and intensity of occlusal contacts, allowing practitioners to measure the dynamics of occlusion rather than evaluate the static condition alone.

DIGITAL RADIOGRAPHY
One of the new technologies that opens many windows previously unavailable to practitioners is digital radiography. The recorded image is instantly viewed, making it possible to rapidly assess the need for any adjustments. Because the image is encoded digitally, it can be manipulated electronically in many ways. Dental professionals have the power to remove extraneous information, adjust contrast and density, zoom in on one or more areas, and reverse black and white - all to enhance the image. Often color may also be used. Although it has not been determined whether color improves diagnostic capability, the color picture makes an impression on the patient and potentially can have a significant impact on oral hygiene compliance. Already available in Europe, a digitized, panoramic machine will also be available in the near future for use by dentists in the United States.
Perhaps the most important benefit of digital radiographs to patients is that, depending on the modality and the application of the device, reductions of ionizing radiation may be from 50 to 90%. This reduced radiation, together with the ability to manipulate images, makes filmless radiography particularly useful during the try-in stage.

Without causing potential patient apprehension over repeated exposure to radiation, the dentist can quickly and easily evaluate the fit of a restoration and adjust and recheck it as necessary. Interproximal margins, for example, can be checked easily using digital radiography. Images taken during the final visit also can help illustrate maintenance measures that the patient must take to preserve the restoration.

Once images are acquired, they may be filed electronically using the computer hard disk or other storage media, such as optical disks or CD-ROM. They can also be sent by modem to a consulting dentist, reducing the time involved and eliminating the need for patients to transport films from one dental office to another. Both practitioners can look at the same images simultaneously, facilitating complex treatment planning. Images may be filed chronologically, recalled, and compared side-by-side while viewed on the monitor.

PATIENT EDUCATION SYSTEMS
Increasingly, the operatory monitor is being used as a method for conveying information to patients about procedures, follow-up, and maintenance. Video or CD-ROM programs, about 2 to 5 minutes in length, may be viewed during "down" time, while the patient is in the dental chair between each phase of treatment. This enables the entire appointment time to be utilized more efficiently. Similarly, monitors in the reception area and consultation room can provide educational programming. Depending on the system, patients may be able to select topics that interest them from an interactive menu. By integrating education throughout the treatment, rather than relegating it to the end of each visit when patients usually are tired and eager to leave, there is a greater likelihood that patients will pay attention and absorb the material. It is hoped that they will realize that their on-going home care is an integral part of their treatment.

SUMMARY
Computer technology has revolutionized the way the world does business, allowing us to work faster, smarter, and more efficiently than ever before. Within dentistry, that translates to x-rays that use significantly smaller amounts of ionizing radiation, automated periodontal charting and storage devices, and imaging systems. Perhaps the greatest bottom-line benefit, especially in esthetic dentistry, is that these state-of-the-art developments enable dentists and hygienists to more effectively communicate with patients. The future of any restoration is based on the patient's motivation and ability to maintain an efficient oral hygiene routine. Esthetic restorations demand more vigorous home care programs to maximize their esthetic and functional life expectancy. With computerized images on screen, patients can better visualize the treatment that has been done and come to a realization that the restoration's success rests squarely on their shoulders.

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