Health & Wellness

Thanks to New Tech, Baltimore Dentists are Upgrading The Patient Experience

Open up and say—’AI?'
—Illustration by Alicia Corman

If you’ve had a crown, an implant, worn a night guard, or needed braces or dentures, chances are that you’ve had impressions done. In case you don’t remember, that’s when your dentist or hygienist fills a plastic—or decades ago, metal—form full of goopy stuff, puts it into your mouth, and then holds it there until it hardens.

There were times I had this done when I gagged and swore that I was going to choke to death on the goop. Then, when my dentist pulled it out, the pressure was so great, I thought all of my teeth were going to come out with it.

Spoiler alert: They didn’t.

While I’ve never feared going to the dentist, let’s just say I was never thrilled with knowing I’d need impressions. Luckily, for me and so many others who may need to get impressions, dental technology has advanced to the point where that goop, as well as many other procedures, is becoming a thing of the past.

So let’s take a look at some of the latest advancements.

Goop Be Gone

Not only did the impression material—heretofore described as “goop”—cause issues for patients, Dr. Anthony Hamod, DDS, partner of Bel Air Dental Care in Fallston, says that it sometimes wasn’t as accurate as what’s being used now.

“When you take a mold that way, the hard tissue is going to be captured accurately in the impression materials, but as it hardens, it pushes the gums out of the way. So when we create a static hard model of what we think is in your mouth, the gums may not be as accurate,” Hamod says.

Today, Cone-Beam Computed Tomography, better known as CBCT, has changed all that. CBCT is a medical imaging technique. With it, dentists are able to take thousands of images of the patient’s teeth, mouth, gums and more—which appear immediately on the screen for the dentist to see. In Hamod’s practice, the machine they use takes up little room and has a small carbon footprint as well.

These scanners not only show 3D images of patients’ teeth and gums, but colors show up to indicate bite pressures—where the patients bite down harder on a particular tooth or teeth. Seeing this, dentists can check those specific teeth in the future, as they are more inclined to get loose or need root canals.

Deanna Birch, an assistant as well as a patient at Bel Air Dental Care, has had the goop impressions in the past and, more recently, has had the digital scanning.

She says that she prefers the scanning method, as they’re finished quickly. And are, well, less yucky.

“The scan is more accurate too,” says Birch, of Joppa. “Patients love it. Because when they would come in needing impressions, they would stress out about it. Some have the gag reflex, and that’s not fun. This is much better for them.”

Bone Collectors

CBCT technology is also being used for more involved dental surgical procedures. Dr. Sanju Jose, DDS, MDS, partner in the Columbia Center for Implants & Periodontics, uses the CBCT for implants (artificial structures that replace missing teeth), but additionally for creating bone grafts.

For example, if a patient who needs implants doesn’t have enough bone to hold them, dentists such as Jose can do procedures to actually regenerate it.

This normally involves mixing biologic activators with processed cadaver bone. An example of how this can be applied is when titanium mesh is formed over the patient’s existing bone, which will hold the bone in place and not allow the soft tissue to sink inwards.

Jose says that although titanium mesh has been around for some time, in the past dentists would have to trim it chairside, which could leave sharp edges.

“If one of the parts of the mesh was sharp, the gum tissue would start to open up. In studies, it would show that in almost 40 percent of cases, the titanium mesh pieces were sharp, the gums can open back up, and you don’t get the bone regeneration you were expecting,” Jose explains.

With CBCT, he can print a 3D model of the patient’s jaw, then put the titanium mesh over it and use wax to mimic the bone graft he wants. “Then I actually cut pieces of mesh to fit, because what you want is the mesh to adapt to the surrounding bone. I smooth out the sharp edges, sterilize it, and it drops right in during surgery.”

He also uses CBCT to get a 3D look at what the patient’s mouth actually looks like. “It shows you the full volume of the patient’s bone anatomy. You’re not guessing. I don’t want to go into surgery and think, ‘This is how much bone I think I have,’” says Jose. “With the 3D image, I get to see the sinuses, mark the nerves, and see all the anatomy.”

The software allows you to plan what diameter and depth the implant should be. This is especially important if a patient needs to have multiple implants and eliminates any guesswork.

“Let’s say you’re missing four front teeth. Now we can digitally create what those four front teeth should look like to match the adjacent teeth, taking into consideration aesthetics and function,” says Jose. “All of this—from the bone anatomy to the implants—can be preplanned. The lab will imprint a guide that’s custom to that patient. It makes the surgery faster, and everything goes into the mouth exactly where it should.”

When Jose does a full-mouth reconstruction, he now uses a facial scanner as well as CBCT and an intraoral scanner. Within a few minutes, he can capture the patient’s face and lip movements. This enables him to see their jaws moving, their gums, and their bone—the entire face.

“I can now design everything and see it digitally before we do the surgery,” he says.

3D Printing

The use of 3D printing is revolutionizing dentistry as it has so many other fields. While 3D printing has been used in the dental industry since about 2008, says Hamod, it was originally only used to print crowns.

“And of lot of dentists still do that if the logistics of their offices allow for it. A 3D printer prints your crowns while the patients are in the chair,” he says. The dentist then will glaze and stain the crown and then put it in before the patient leaves. The whole process takes approximately 1.5 hours for a single unit crown.

The same-day crowns, made famous by a company called Cerec, have the advantage of saving the patient multiple visits and a three-week turnover time. Not to mention they spare the patient having to deal with the risk of fracturing or losing the temporary crown. The downside is that the dentist’s office has to have an extra operatory (room with dental equipment) available to keep the patient waiting while the crown is manufactured. They are also not as durable/cosmetic as a laboratory-fabricated crown.

Hamod says that even dentures are 3D printed by labs today. Beginning in about 2020, dentures were just starting to be 3D printed by a few labs, but today, every major dental laboratory is able to print 3D dentures.

Dental offices also use 3D printing to make surgical guides, like those used for implants which are essentially 3D maps that fit in a patient’s mouth. Hamod explains that the guides direct the dentists as to where the implants must go.

“They click onto a patient’s teeth and allow us to place in the implant exactly where it belongs with the correct depth, angulation, and rotation,” explains Hamod. This takes all the guesswork out of the implant procedure. “In the past, [surgical guides] were called ‘wish guides’ because we would try our best to guestimate where it should go based off of where the tooth should go—but not necessarily where the bone was.”

What makes these 3D printed guides work so well is the fact that dentists use them in conjunction with CBCT. They are more accurate than traditional X-rays and provide dentists with more information. In this way, they can see the bone that will house the implant and place everything exactly where it needs to be.

They, Robots

Robotics has become another useful tool for modern dentistry. Before you freak out, no, a robot is not doing your surgery—the dentist is. Jose, whose practice was the first in Maryland to have robotics, explains that robotics aren’t always needed. In most cases, the surgical guide is sufficient.

“It’s great; it’s quick, and it’s accurate,” he says. “But it is surgery. And sometimes you have to deviate.” The problem is that the surgical guide won’t allow for any changes; what you see is where it goes. But with robotics, if Jose realizes that he needs to make a change, he types it into the computer program, and then the Yomi robotic system—the only one currently approved by the FDA—is able to help him complete the surgery using the new diagnostics.

The robotic system doesn’t look like a human. Imagine a white cart on wheels. On the top of it are two computer monitors as well as a laptop— these help the dentist conduct the surgery while seeing what they’re doing in real time. A robotic arm comes out of the main machine, and it will guide the dentist’s drill.

If Jose makes a change, as described above, when he uses the drill, which is attached to the robotic handpiece that fits into the arm, the robotic system will move it to make sure he is drilling in the exact right position in the patient’s mouth. It won’t allow him to deviate—unless he specifically changes the diagnostics in the computer.

“It allows me to deviate the plan in a positive manner—meaning no errors. Because the robotics movements are live,” says Jose.

The Future is AI

When you mention AI being used in dentistry, people tend to stress out because they believe this means eventually dentists will be replaced by machinery.

According to Dr. Jeffery Price, DDS, MS, MADG, FICD, FACD, and Dr. Ahmed S. Sultan, BDS, PhD, co-directors of the Division of Artificial Intelligence Research at the University of Maryland School of Dentistry (UMSOD)—the first AI division in the first dental school in the world—you don’t have to worry.

“In fact, the American Dental Association prefers the term ‘augmented intelligence,’ as it means a human and a machine are working together,” explains Price, also a clinical professor and director of the Division of Oral Radiology at UMSOD. “Artificial intelligence would be the human turning over all decision-making to the machine. Augmented intelligence plus the clinician will result in a better outcome for the patient.”

Sultan says what he foresees happening in the dental world is AI-powered assistants that have ambient note capabilities. “So whenever the clinician is talking to the patient, it takes that data and populates it in a clinical note. That’s really helpful because it allows dentists to sit down and talk to their patients and not waste time writing up the Electronic Health Record [EHR].”

It will be much like the system that your primary care physician may use. “And 90 percent of the time, you can actually have a connection with your doctor,” says Sultan, an assistant professor and program director for the Oral & Maxillofacial Pathology Residency Program at UMSOD.

Price adds that these assistants can put the information gathered into searchable fields so that, after a certain amount of time, “You’ve got data that’s reliable, and algorithms can search it and provide information for research purposes.”

Eventually, this could help day-to-day dental care as well, like when dentists spot something that may be oral cancer. “With AI, if they have a question about a lesion in someone’s mouth, they can take an intraoral picture of it, and with the growing advent and presence of AI, they will get an answer in 30 seconds or less,” says Price. The dentist can then decide the best course of treatment action. Sultan adds, “AI is really good at the flagging system. So, it can flag the dentist on things that are really subtle.”

As technology continues to advance in dentistry, it’s not just to make life easier for dentists.

“Ultimately, it’s all about the patient,” says Jose. “You want to be able to deliver the best care to the patient.”

If that best care means less goop and more 3D imagery, count me in.