Friday, December 2, 2016

Is there more to Orthodontics & Dentistry than just Technology?

Is there more to Orthodontics & Dentistry than just Technology?
I have practiced Dentistry for 20 years; I have worked as a hospital dentist, a sole practitioner general dentist, an orthodontic resident and now, for the last 15 years, as a sole practitioner Orthodontist in arguably one of the most progressive and tech-savvy cities in America.  In this time I have seen the introduction of computers, the use of software to organize schedules and billing, the advent of electronic claims for insurance, the development of the Internet and the introduction of the digital age.  Lasers were introduced first for soft tissue incising and then for hard tissue preparation.  I have seen film-based radiography morph into computer imaging and have watched as digital images were created from three-dimensional laser-scans; digital files that were then used with new milling machines that could transfer the digital world back into porcelain crowns and prostheses.  In Orthodontics, this digital age introduced the advent of clear aligners made from sequentially altered digital scans of entire dental arches allowing incremental changes (tooth movements) to correct mild crowding.
With all of these wonderful technological advances, it may be prudent to stand back and balance the new shiny tools and machines with the older and well-tested dentistry of the recent past.  Today, technology is pushed by large dental supply companies to young dentists and specialists as almost a status symbol of modern dentistry; a kind of litmus test of how modern and up-scale a dentist may be perceived.  But is this really a good way to judge a dentist or Orthodontist?  Is there some point of diminishing returns where technology is just more expensive?

In addition to all of the “wonderful” technological advances, I have seen overhead climb from 50% up to 75% or more in “modern” dental offices.  Radiograph machines are now $80K to $150K up from $10K in the past and since they are digital, they come with expensive software and regular updates that challenge existing hardware and may lead to obsolete machines within just 5 years.  It used to be a dentist could count on 20 years for almost every item in their office but now computers must be all replaced to keep up with new operating systems and added hardware such as printers and scanners.  Software programs will cost a new office $25K to $40K initially with a “forever” maintenance fee of $2K to $4K yearly even if you have your own server however we now can expect higher Internet fees ($200/mo or more) as we move to cloud-based systems and un-ending revolving charges to keep the system working seamlessly. 
On the treatment side, the digital age brings more automated systems that reduce doctor time (and sometimes patient time) driven by a need to produce more (to pay for the new overhead) in less time.  Crowns can be made in a single visit as teeth are digitally scanned and porcelain is milled in special machines (another $50K to $75K) and aligner trays can be made to move teeth (at 10x the cost of braces) albeit with less accuracy and many more limitations.
This has driven up costs and made the sole practitioner less common than larger multiple doctor offices and companies that can share these expenses.  This trend has also lined many pockets along the way from software companies to computer companies, from third-party labs to local and regional dental supply companies and of course companies that have learned to employ dentists that cannot afford to keep up with the Dr. Jones’ of the world.
But is there something inferior to lab-built porcelain crowns?  Is the new material better than the old?  Is the technology actually better than the doctor’s own hands and skills?  Perhaps in some cases, maybe in many cases but the truth is that there are still many things the doctor can do better without the newest technologies.
Laser scanning a tooth prior to preparation of a milled crown 
“Is the technology actually better than the doctor's own hands and skill?Perhaps in some cases, maybe in many cases but the truth is that there are still many things the doctor can do better without the newest technologies.”

Milled single-day "advanced" crown (dull, monochromatic and bulbous)
Hand-stacked laboratory fabricated crown; beautiful and natural with blended color to match teeth
Hand-made, Lab-fabricated crowns can be very beautiful by matching color variations and translucencies of adjacent teeth and matching the sizes of existing teeth more exactly while milled crowns have a tendency to be more opaque and mono-chromatic even to the point of looking like “chiclets” (referring to the white rectangular chewing gum).  Lab crowns may take 2 weeks to return from a good lab, and yes there is a lab bill for $100 or so per tooth, but there is no scan or milling machine necessary that must be paid for before it becomes obsolete.
Milled single-day crowns, opaque and "Chiclet gum" appearance

Beautiful laboratory hand-stacked fabricated crowns with natural translucency and color

Lab-created aligner trays are heavily advertised to the public as “Invisible Braces” in attempt to equate them to braces; these trays are made from laser scans sent to third-party companies (Invisalign, Clear Correct, etc.) and they appear to move teeth like braces but in fact, research from the Journal of the American Association of Orthodontics & Dentofacial Orthopedics (as well as any good orthodontist’s own experience) has repeatedly shown accuracy of movement to be on average, a dismal 18% to 57%.  These aligners will many times leave patients with poor or even no posterior occlusion which can then lead to excessive incisal wear and possible TMJ over time (see my blog Does Invisalign Work as Advertised?) 
Digital radiographs are convenient and fast (I certainly do enjoy the positive aspects of my digital machines) but they are not necessary to treat patients v. the older standard film based radiographs and in some ways are inferior.  Once an office goes digital, you can add another 10% to the overhead and therefore to the costs of treatment.  If you choose 3-dimensional radiography, expect anther 5% overhead for pretty pictures that are simply not necessary for the majority of cases and will introduce significantly more radiation.

Modern Cone-Beam Radiographic Machine


In short, dentists and dental specialists (Orthodontists in particular) must weigh the advantages of new technology v. the added overhead, the shortfalls and the maintenance of such advances.  As doctors, it is our responsibility to offer the best treatment, even if it is not the newest or most trendy available (i.e. braces v. Invisalign) and we should strive to keep patient costs down by keeping our own overhead reasonable.  If we continue to equate quality with technology, we will most certainly end up with automated dental care and faceless companies treating patients (usually to some average parameter instead of providing specific and unique quality care to each individual patient) and will lose the ability to develop a real doctor-patient relationship. 

3-D Image of the skull with Cone Beam Radiography
“dentists and dental specialists Orthodontics in particular) must weigh advantages of new technology v. the added overhead, the shortfalls and the maintenance of such advances.  As doctors, it is our responsibility to offer the best treatment, even if it is not the newest or most trendy available ..”

If you have questions or comments concerning this or any orthodontic question, please feel free to make a complimentary new-patient appointment at either my Steiner Ranch location or my North-central Austin location on West 35th street and MoPac.
Dr. James R. Waters is a 1996 graduate from UTHSC Dental School in San Antonio, 1997 graduate of Advanced Dentistry from the UNMC in Nebraska and the 2001 Valedictorian graduate from the prestigious Saint Louis University Orthodontic Program receiving the J.P. Marshall award for clinical excellence in 2001.  He holds a Bachelor’s Degree in Science, Doctorate in Dental Surgery, a post-doctorate certificate in Advanced Dentistry, post-doctorate Degree in Orthodontics & Dentofacial Orthopedics and a Master of Science Degree in Orthodontics and is a Diplomate of the American Board of Orthodontics.  Dr. Waters and his wife of 20 years live in Austin, TX with their 4 children where he has a thriving, multi-faceted Specialist practice with locations in Steiner Ranch and North-Central Austin.  You can learn more about Dr. Waters at 

Steiner Ranch Orthodontics
4302 N. Quinlan Park
Austin, TX 78732

Contemporary Orthodontics & Dentofacial Orthopedics
1814 W. 35th St.
Austin, TX 78703