Boys & Toys

Oct. 1, 1999
Dentists buy two types of techno goodies: (1) practical, useful, and cost-effective tools, and (2) fun, amazing techno-toys. Techno-toys are bought not because dentists need them, but because they want them. Many dentists have shelves full of toys they "had to have," but never managed to use effectively. It`s OK to buy techno-toys as long as doctors realize that`s what they are doing. On the other hand, to use technology effectively, they will have to buy with care and put some effort into setti

Is Doc overloading the office with high-tech gadgets? Maybe you can figure out how to use them.

Larry Emmott, DDS

Dentists buy two types of techno goodies: (1) practical, useful, and cost-effective tools, and (2) fun, amazing techno-toys. Techno-toys are bought not because dentists need them, but because they want them. Many dentists have shelves full of toys they "had to have," but never managed to use effectively. It`s OK to buy techno-toys as long as doctors realize that`s what they are doing. On the other hand, to use technology effectively, they will have to buy with care and put some effort into setting up and using new systems.

Starting with the intraoral cameras introduced over 10 years ago, we have seen a steady advancement of high-tech tools for the esthetic and restorative practice. These include intraoral cameras, digital capture of intraoral-camera images, digital radiography, digital still cameras, image-management software, and cosmetic-imaging software. The developing technology in these areas is so remarkable that it is easy to get caught up in the excitement of it and buy without consideration for how to make it work profitably in the practice. Offices that profit from technology follow a logical sequence in its purchase and application.

Dentists are attracted to the visually exciting technology and often want to jump into advanced imaging systems without first developing the more boring infrastructure for the technology. However, few offices will see a true return on their technology investments if they don`t lay the proper groundwork. Steven Covey declared that the third habit of highly effective people is to "put first things first." If you want to profit from high tech, you will need to follow that advice.

The first step is to set up a good, Windows®-based, networked, practice-management system. The second step is to move the computers into the treatment rooms and start doing chairside data entry, electronic-charting, and chairside scheduling. Many people are skeptical when they first hear about using computers in the treatment rooms. It doesn`t seem right, and they come up with lots of excuses as to why they can`t do it - they`d be in the way, I`d never use them, I don`t have enough room, other staff members won`t like it, it is too expensive, etc.

However, once the computers enter the treatment rooms, everything else changes. It opens the way for adding on all the wonderful high-tech systems and making them work profitably in the office. Conversely, trying to use image management and cosmetic imaging without chairside computers is expensive and difficult. Good examples of Windows®-based, complete practice-management software are Dentrix and Practice Works.

Intraoral cameras

The single, best technology investment a dentist can make is an intraoral camera. You can buy and use a camera without treatment-room computers.

However, we are rapidly moving from an analog video world to a digital world. That means that it no longer is necessary to use a video printer to freeze display and record intraoral images. It no longer is necessary to have big TV monitors in every room with a hard-wired network. Using the computer to capture, store, retrieve, and manipulate images is much more flexible than old printer-based systems.

Once there is a computer network with computers in every room, the computer network becomes the video network. The computer becomes the printer (that is, it freezes images) and the computer monitor takes the place of the TV.

Putting a computer in every room just to capture an intraoral image doesn`t make much sense. However, adding image-capture to an existing system is easy and cost-effective.

Image management

The next logical step is to add image management. That calls for software which captures, stores, and retrieves images. These can be captured camera images, images from a digital camera, or scanned and digitized images. Image-management systems create a kind of photo album of images, which are linked to an electronic patient chart.

Advanced systems also will allow you to display various images for before-and-after comparisons. They also make it easy to arrange and print images. The newest systems provide for easy transmission of images via e-mail and the Internet. Tigerview is a good example of an image-management system.

The next high-tech tool to consider is a digital camera. Digital cameras range in price from under a hundred dollars to several thousand. To be useful in the dental office, the camera must take a close-up of the mouth only and a three-quarter to full-face shot without distortion or wash-out from the flash. You also need a fast method to transfer images from the camera to the computer. The best way is with a flash memory card or a floppy disk.

Good models to use are the Olympus 620, the Sony Mavica 91, or the Richo RDC-2.

You now are ready to add cosmetic-imaging. This is software that allows you to manipulate the picture of a smile to simulate the results of cosmetic treatment. Cosmetic-imaging hit dentistry a few years ago and, after a brief period of interest, seemed to die out. It declined because it was hard to do, took a lot of time, and was expensive to buy and set up.

Cosmetic-imaging now is making a big comeback. It`s coming back because new software systems have tools that make cosmetic manipulation fast and easy. It now is much more cost-effective to add imaging to an existing computer network. It should not be a stand-alone system, but part of your overall technology system. The two leading image-management and cosmetic-imaging software systems are Image FX and Vipersoft. If you use one of these imaging programs, you will not need separate image-management software.

Digital radiography

The final piece of the puzzle is digital radiography. It could be added before the camera and imaging is put in place. It is remarkable technology that promises to completely change how we take and analyze radiographs. Again, first things first. It is possible to use digital radiology with a cart system rolled from treatment room to treatment room or, worse, to use a laptop. The end result is a system about as useful as a cart with a rear-mounted horse.

After all, where do you most need a radiograph? It is in the treatment room. If you don`t have networked computers in all the rooms, it is awkward or impossible to bring the X-ray image into the room. Also, if the images are not linked to an electronic chart in a management system, it is awkward and time-consuming to find and retrieve images. As a rule of thumb, if you don`t have electronic, paperless charts, you aren`t yet ready for electronic, paperless-digital radiographs. On the other hand, adding digital radiography to an existing treatment-room-based computer network is easy and less expensive than trying to set up a stand-alone system. The new leader in this field is Trex Trophy.

Learn to use systems

It is amazing how many dentists spend tens of thousands of dollars on technology and never spend a penny on learning to use it properly. Training is not an option. For example, you could be equipped with the world`s best chair, unit, and handpiece, but it wouldn`t make you a great hygienist. You would be a great hygienist only after you had studied, practiced, and mastered the skills of fine preventive and periodontal dentistry.

The dental handpiece has value only in the hands of a master. Technology is the same way.

To profit from technology, hygienists need to use what the doctor buys. Technology tends not to be used if it is too hard to use, takes too much time, etc. Be careful not to fall into old ruts and just "get by" doing what you`ve always done, and let the techno goodie sit on the shelf.

Be prepared for it to "take too much time" and be awkward the first (and probably the second and third) time you use it, but don`t give up - just get better. Establish protocols and time schedules for the use of technology.

For example, you may wish to set a protocol that all new patients will have a digital picture taken and a cosmetic-smile design presented at the consultation appointment. Or, you may set a protocol that all patients who have whitening or anterior bonding will have a before-and-after image in their digital charts.

Another way to use these tools is to prepare customized case presentations. These can be word-processing documents, which include copies of the patient`s own photos and X-rays, as well as enhanced cosmetic images. These are combined with text specific to that patient describing the need for and benefits of treatment. For major cases involving elective treatment, these will help the patients understand and accept proper care. In other words, the high-tech tools will increase case acceptance and ultimately profit the office.

Once the protocols and templates are established, hygienists can prepare these incredible documents in less time than we used to spend writing up a treatment plan or case report by hand.

Budget for technology

The final step to profiting from high-tech tools is to establish a technology budget. Money should be spent every year on improving the technology infrastructure and on the training and development of the staff.

A recent Wall Street Journal article indicated that the average health-care company (including hospitals) spent 2 percent of gross annually on technology. By comparison, the average business overall spent 10 percent on technology. A dental practice should establish a budget of at least 2 percent. If an aggressive high-tech office is desired, a budget of 5 percent or more may be necessary.

Planning with a budget is important for several reasons. The most significant reason is psychological. That is, a dental office already has planned to spend the money and is less likely to put off important items, such as training, because of cost. The second thing a budget does is focus attention on what to buy. The doctor will be less likely to purchase toys and more likely to purchase tools to stay within the budget.

Developing a high-tech practice and profiting from high-tech tools is an ongoing process. Be careful to avoid toys and concentrate on tools. Establish an infrastructure which will support advancements in technology. Add on new technologies in a logical sequence. Obtain ongoing, advanced training for the entire dental team. Establish goals and use new technologies on a daily basis. Finally, set up and follow a budget.

The future is coming ... and it will be amazing!

Larry Emmott, DDS, is a practicing general dentist in Phoenix, Ariz. He is a featured speaker at the Las Vegas Institute He has written many articles for national magazines on dentistry, computer use, and management. He produces a monthly newsletter on management and computer use in the dental office. He has developed and maintains an Internet Web site at; his e-mail address is emmott@

Pearls for Operating Intraoral Cameras

For more than a decade, experts have been extolling the virtues of the intraoral camera, including that it is one of the best tools available for educating patients about ideal dentistry.

Once a dental practice makes the commitment to purchase a camera, the team discusses where the best place is for housing the unit. Most practices decide to put the camera in the dentist`s operatory. This is fine for dental practices that have purchased a multi-operatory system. However, if the camera is only used by the dentist during new patient exams or treatment consultations, then the ideal place for the camera is in the hygiene arena. The dental hygienist is the primary educator in the practice.

What many practices do not realize is that 40 to 80 percent of the dentist`s scheduled therapy comes from the hygiene recare appointment. The hygienist gathers the diagnostics, completes the preliminary exam, and predisposes the patient to treatment recommendations. Since the hygienist spends so much time educating the patients, it is only natural that the camera becomes an integral part of the hygiene recare visit.

Many hygienists are concerned about how to find the time to use the camera during the already hectic recare visit. Consider incorporating the following protocol in order to improve your time management:

* Review the medical and dental history, as well as the chief complaint.

* Take radiographs.

* Tour the mouth with the camera. If time is at a premium, then go right to capturing four images with the camera.

* Hand the patient some brochures about the dentistry you will be discussing.

* Excuse yourself to go and put the radiographs into the developer.

If you manage your time well, and keep moving at a steady pace, you can accomplish these tasks in about five minutes. Once the patient sees the benefits of ideal dentistry, the recare appointment becomes an effective educational arena.

What follows are some pearls of wisdom that will help "camera shy" hygienists get started with the intraoral camera and use it effectively.

_ Utilization - People who are extremely successful with the intraoral camera begin using it the first day it arrives. You have to use the camera. Have a four-split picture on the screen of great dentistry before the patient comes in the room.

_ Patient positioning - It`s very important that the patient be seated in an upright position. The camera should be down at the patient`s foot or knee. Stand behind the patient so you both can see the screen. Gently glide the camera through the mouth commenting on what you see as you go along. The live tour of the mouth has the greatest impact on patients.

_ Introduce the power - Many times, not knowing what to say, we will simply stick the camera in the patient`s mouth. Give a demonstration of the camera`s power by aiming the camera at the patient`s ring, watch, or shirt. As the camera magnifies, say, "As you can see, Mrs. Smith, the camera will magnify 20 to 30 times its original size, thus allowing both you and I a better opportunity to see your dental condition."

_ Prop the camera - This is a simple tip. Do not waste time free-holding the camera out in the middle of nowhere. You`ll never get a steady enough hand and you will have a blurry picture. Rest the handpiece on the opposing arch much like we fulcrum our fingers on the opposing arch for use with our instruments.

_ Start with the positive - It is important that we show a healthy tooth first and then cross-reference with other areas you may have concern with. You don`t want to appear as if you are only going to point out the problems. Glide the camera around the arch until you notice a normal, healthy, well-restored tooth.

_ Keep it simple - You are using some of the most upscale technology we have in our arena today. Do not use 50-dollar dental words that defeat your purpose in the communication process. Keep it simple. "See this black area? It`s a very large, leaking, silver filling and it would benefit from a more permanent restoration."

_ Get the patient involved - If your camera has a remote control, give it to the patient. Let the patient help capture the images that you both discover. The patient will retain more, learn more, and refer more if they get involved in the process. Don`t forget to purchase the CD-ROM educational programs that are available with your particular camera.

_ Two copies - Once the tour is completed and the patient has discovered the necessary dentistry, print two copies of the photo - one for retention in the patient file and the other for the patient to take home. After the financial presentation, the patient leaves the practice with a treatment plan, a brochure about the needed dentistry, and the photo. The visual impact of the necessary treatment lingers long after leaving the office.

_ Offer the best option for treatment - When the patient can see the dental condition for themselves, the attitude of "Let`s just watch it" is very seldom what the patient requests.

This article was written by Cynthia McKane-Wagester, RDH. She is the founder of McKane & Associates, a full-service management company. She can be reached at her offices in Maryland at (800) 341-1244.

Cruising with Jane

I am not a "cyberspace guru," but during the two years that I have had this wonderful invention (my "puter," as I like to call it), a world of information has been opened up to me.

The first site that I visited was a wonderful resource. The Web master is a male hygienist who puts so much of himself into this wonderful site. You can visit virtually anywhere in the dental field through his links. Visit this completely interactive dental site and see its features that include surveys, job banks, forums, and lots of other fun things to do. The URL is: friend.

The next site that I visited on my tour through cyberspace was one that a student in dental hygiene school had developed. Of course, that student is now a licensed dental hygienist, and she has incorporated places in the site for hygienists. Visit this URL: CollegePark/Gym /5147.

From there, I found a site hosted by "Ms. Flossy." Ms. Flossy`s Dental Hygiene News is in a small corner of cyberspace. Hygienists can review and gain new information about the profession. Information on the site is written in plain, easy-to-understand language for all cyberguests. This site also includes a forum for guests to leave questions and comments on a variety of dental subjects, an RDH registry list, an extensive list of dental hygiene educational facilities, and a chat room that meets every Sunday night at 8 p.m. EST. Hygienist`s can also send out e-mail confirmation cards to their patients or e-mail greetings from Ms. Flossy`s web site. The URL for this site is:

The last two sites I will mention are two educational and informational sites that I think we all must visit from time to time to keep up with new things on our "hygiene horizons." The first is by Procter and Gamble and, believe it or not, you can actually get online CE credits from this site - at your own pace! The URL for this site is: http://www.dentalcare. com.

The second site is operated by one of our own wonderful hygiene educators, Margaret Feherenbach. It is a site for dental hygiene patients, students, instructors, and practitioners. It has information on dental care, online education, important Web links, seminars, and publications. The URL for this site is:

Other sites are directed to specific issues, such as reciprocity, preceptorship, and other controversial issues. An example is a site by a fellow hygienist: http://www.flash. net/~aonstad/rdhcampaign.htm.

Jane Weiner, RDH, who conducts board review courses for hygienists, can be reached at (954) 722-6759 or by e-mail at [email protected].

Viewing Conditions Affect X-Ray Quality

The exposure settings are right. The processor is working exactly as it should. The radiographs that your office generates are crystal clear.

Yet the dentist may still be missing diagnostic information. Why? Because he or she may not be examining those radiographs under proper viewing conditions.

Viewing conditions can drastically affect the way the human eye sees. The most dramatic evidence of this is something everyone has experienced. You`ve been outdoors on a sunny day. You step inside, into a curtained room, and for the first few moments, you can barely see a thing.

Similar visual effects can occur when viewing dental X-rays. Improper viewing conditions can trick the eye into missing structures that would otherwise be detected. And, sadly, the result could be undiagnosed caries or other conditions the dentist would want to address.

One of the most important characteristics of a dental X-ray is contrast. In lay terms, contrast is the difference between the shades of gray that make up the image. An image has good contrast if the lightest parts are very light, and the darkest parts are very dark. In an image with good contrast, even slight differences in the structures are visible. Many factors can influence the contrast of an X-ray, from radiation dosage to the temperature of the processing chemistry. Viewing conditions can also affect contrast.

For example, hold a dental X-ray up to a window with plenty of sunlight. Then mount the same X-ray on a viewbox, turn down overhead lights, and mask the image (cover the background area so that only the X-ray image shows through). The difference will be obvious. The image mounted on the viewbox will appear to have much better contrast. You`ll be able to see subtle details in the image that were virtually invisible when you looked at it in front of the window.

So what are the steps to improving your office`s viewing conditions?

_ First, use a viewbox. Quality viewboxes are designed to provide the even, bright light you need to illuminate diagnostic images. If your practice doesn`t own a viewbox, start shopping today. Viewboxes are sold by all suppliers of dental equipment. Look for one that provides diffused light of uniform brightness. If you need more than one viewbox, make sure all have lamps of the same color and brightness.

_ Mask the image. After you`ve mounted the image on the viewbox, block the light surrounding the radiograph so that only the X-ray itself is lit. Some offices use pieces of cardboard with sections cut out in the shapes of the film chips. Whatever technique you use, masking will dramatically improve the apparent contrast of the image.

_ Control ambient light. If the room where you view images has windows, close the blinds. You should also dim any overhead lights during viewing. The room should not be pitch-black, however. Subdued light is best. It helps keep the eye attuned to the lightest portions of your X-ray images without making them appear overly bright.

_ Watch for reflection and glare. You should also position any other light sources in the room so they won`t cause reflections to fall on your radiographs.

_ Make the viewing area comfortable. Mount the viewbox in a place that lets the dentist see the images without strain. The images should be at eye-level, for example. This helps ensure the dentist can place full attention on the images, even at the end of a tiring day.

This article was written by Charlie Brayer, a senior development engineer in the Media Systems Development Group in Health Imaging, Eastman Kodak Co. He has been employed with the Eastman Kodak Company since 1979 after receiving his degree in chemistry from the State University of New York at Geneseo. For more information on how to improve viewing conditions, or any other aspect of dental X-ray quality, call Kodak`s dental business customer support hotline at (800) 933-8031 or visit their website at