Abstract
Dental practices use multiple imaging modalities daily, and different systems produce data in various file formats, often requiring information to be stored in a particular software platform. This siloed approach to clinical image management can lead to challenges with efficiently using data for diagnosis, treatment planning, and patient education. However, practices and patients can benefit from implementation of a connected system that stores all patient radiography, photography, and 3D data sets in 1 platform that offers customization, efficiency, and flexibility.
Learning Objectives
- Understand the current landscape for clinical image management and its shortcomings due to multiple siloed image capture, storage, and viewing platforms.
- Learn how dental practices can benefit from having a central hub for all sources of clinical radiography and photography.
- Understand the efficiencies of connecting all imaging technologies to a central platform that can be a hub for communications and data.
- Learn about the benefits of customization in image management and presentation.
- Understand how advanced software can automate laborious tasks, enhance practice efficiency, and improve patient understanding of treatment proposals.
During the past 15 years, numerous technologies have come into the dental office, allowing forms of imaging ranging from a simple periapical radiograph to a 3D full-color facial scan. These technologies provide valuable data that can be used to synthesize a proper treatment plan; however, until recently each of these data sources typically resided in a different area and was accessible only by utilizing a multitude of software platforms. For one to examine the digital image gathering in a new patient’s journey, it is very likely extraoral photography will occur, an intraoral scan will be taken, a low-dose CBCT will be captured, still images may be taken within the mouth with an intraoral camera, digital intraoral radiographs may be captured with sensors or phosphor plates, and one may even gather near-infrared images as well as facial scans.
Once all these data are gathered, they may be stored in multiple areas including a standalone computer tied to a CBCT and an individual gaming laptop paired with an intraoral scanner. Photographs may be unlabeled on SD cards, and facial scans may be on a separate storage device. In addition, intraoral radiographs and images may be organized in 2D imaging software tied to a server.
With the many imaging technologies in a practice today, a clinician often must jump back and forth between multiple windows and computers in different rooms to view and study all data that have been captured. This can be inefficient and does not allow the ability to bring all the information together in 1 place or to merge data sets. Furthermore, sharing all the data with colleagues for comprehensive treatment planning can be complicated; third-party file sharing services need to be utilized, and each piece of the acquired data set needs to be uploaded separately.
Equally problematic is that the patient cannot view all their information in 1 place, and an educational opportunity is lost if they are forced to follow a clinician jumping between various software platforms. The solution would be a software platform that allows all 2D and 3D data acquired in a dental office to be stored and utilized in a singular hub.
Historically, dental imaging software was simply a place where 2D images were stored, and some platforms allowed 3D volumes to be viewed by launching an additional module. These platforms offered very little functionality beyond simple annotation of images.
The ideal platform for managing clinical dental images would offer improvements in the following areas: accuracy and efficiency; flexible viewing and storage of data; smart features to aid workflow; leveraging data for accurate diagnosis and planning; and collaboration with patients and colleagues.
Accuracy and Efficiency
In years past, imaging for a patient was straightforward. Most patients simply had bitewing, periapical, and orthopantomogram radiographs taken at regular intervals or as symptoms are detected. Today the recommended imaging could also include intraoral surface scans, specific intraoral and extraoral photographs, and 3D CBCT images.
The traditional workflow communicating the need for these images may be simple verbal communication or a handwritten note. This can work, but there is risk of error.
An ideal software platform would allow the dentist to prescribe specific 2D imaging requests down to a particular tooth on a patient as well as the type of device that should be used to acquire an image. In terms of CBCT imaging, the digital prescription should include the region of interest, the field of view requested, and the appropriate resolution.
In today’s world of multiple imaging devices, these scan requests become important for minimizing confusion between team members and for making sure the patient is having the appropriate imaging captured. Furthermore, the prescribed imaging requests should transfer to the hardware being used to acquire the imaging (Figure 1).
Flexible Viewing and Storage of Data
A key challenge with using multiple imaging devices involves storing and being able to view imaging data in an organized, customized manner. Clinicians should have the ability to view all data in 1 spot without having to flip between devices or access computers in different rooms.
In addition, one should not be forced to choose either a Windows PC or macOS ecosystem. Traditionally, dentistry was forced to be primarily PC based. However, today we have intraoral scanners, cameras, and digital sensors that can all work natively in a macOS ecosystem. The flexibility should exist for going back and forth between computer platforms and accessing all data from any computer in the office. All images acquired should automatically transfer and be housed in 1 software ecosystem.
As clinicians view these acquired images, they should be able to set up various layouts pertinent to proper diagnosis and treatment planning. In addition, they should have the ability to present these layouts to a patient in an organized manner, so patients can be properly educated on their treatment needs.
Platforms should allow extraoral photos, intraoral scans, CBCT, and 2D imaging to be displayed simultaneously. The flexibility should be present so that multiple diagnostics layouts for the patient can be created. When a patient has multiple needs, the software should be able to create organized workspaces, with an area having all the corresponding images for a tooth on the upper right side with a problem vs another workspace for the lower left (Figure 2).
Smart Features to Aid Workflow
If one looks at software development outside dentistry, there has been much focus on the user interface and how the end user interacts with data. Although simple functionality of drag-and-drop features has been available in basic consumer software packages for years, this has been missing from many dentistry-specific imaging platforms.
Dental software needs to be intuitive and automated so that basic things such as tooth anatomy can be recognized and used for organizing all images tied to a specific tooth. This automated image management should be able to complete proper sorting of radiographs as they are imported or taken.
Importing 2D radiographs and extraoral images can be laborious in many software platforms. To bring radiographs and photographs into many imaging platforms, images must be imported individually, utilizing multiple clicks. This is far less efficient than simply dragging images from a file into the system. With most dental image management platforms today, each individually imported image must be oriented and labeled to appear properly in the database. In addition, when a radiographic image is acquired, the software must be told on the front end which zone is being captured so that the digital image is “mounted” properly for viewing the full set of images.
An intuitive sorting feature would allow the teeth to be recognized by anatomical landmarks and be placed appropriately into the database to display in the correct sequence when viewed on screen. As software learns to recognize teeth, a focus feature should be available, so that with a simple click on a tooth, the clinician can access all the data available for that tooth. Today, this can be complex and often requires clicking through numerous menus.
An ability of the software to recognize landmarks should also allow the software to merge data sets from different image sources and technologies. If the patient has had a surface intraoral scan and CBCT image taken with adequate overlapping data, a fusion of these data sets should occur in a near-automatic fashion. This fusion allows proper planning for prosthetic, periodontal, and implant therapies (Figure 3).
Leveraging Data for Accurate Diagnosis and Planning
We live in a world where the GPS systems in our cars guide travel and at times automatically update to offer a different route when there is traffic or an accident. In addition, we can tell the GPS our preferences, such as avoiding toll roads or basing a route on time vs distance. As drivers, we are still responsible for navigating the route we believe is best, and the GPS does not replace the driver. Rather, it acts as an aid. Dental image management software today should have a similar guidance ability based on basic parameters we set up within the software.
If we take CBCT technology into consideration, it is incredibly useful in aiding the practitioner in coming to a proper diagnosis for many clinical situations. However, preparing the proper views and slices can be very time consuming. Software today should aid dentists in setting up proper views for common studies of the temporomandibular joint, airway, mandibular canal, and endodontic regions.
Ideally, artificial intelligence would detect all these areas. But at the simplest level, once the clinician identifies a few basic landmarks, the software would then do the rest (Figure 4).
Another key area for leveraging data for accurate diagnosis and planning would involve the identification of edentulous areas and a proposal for virtual tooth replacement. A significant portion of the population is missing 1 or more teeth, and many wish to have these areas restored with dental implants.
For more than 10 years, there has been a focus on having the prosthetic requirements guide the details of the implant placement. However, this is easier said than done.
In traditional workflows, a digital or physical impression would be taken to create a model. The model would then have a wax-up done upon it and this would lead to a model-based surgical guide that would not consider the true bony anatomy.
In more advanced workflows, an intraoral scan could be combined with CBCT images and planning could commence. However, this often requires sending the data from both imaging technologies to a third party for merging of the data sets, or at least exporting the data into a third-party design software. By having this capability built into imaging software, the clinician could easily show the patient a proposed placement of an implant-supported replacement for a missing tooth or multiple teeth by having it virtually placed into an intraoral scan and properly oriented with the CBCT. This allows the clinician to determine whether implant placement is feasible and what specific implant may be utilized for the procedure (Figure 5).
Collaboration With Patients and Colleagues
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One significant issue with dental imaging software has been the ability to share acquired data and collaborate on cases. Clinicians have had to go through the cumbersome task of exporting data sets to various third-party software platforms and then reimporting these images into an individual clinician’s dental imaging software.
Ideally, a simple workflow should allow the referring dentist to decide which data need to be shared, and a single secure portal would be established for viewing all the data. This portal should include some basic tools to allow users to study the images and the clinical information they can provide. This is of particular importance in multidisciplinary cases involving dentists in different locations. Everyone must be on the same page for these cases to be successful and completed in a timely manner. When data is transferred improperly, there can be negative consequences for patient care.
Patient experience is what may drive the profitability and long-term success of a practice. In the past, patients simply did what their health care practitioners told them. However, today’s patient may want significantly more information before committing to a treatment plan.
Nearly two-thirds of all individuals learn visually, and clinicians should use the various image-based data sets to communicate with and educate patients. For nearly 30 years intraoral cameras have been present in dentistry, and many practices have used this technology to educate patients.
The challenge today is that photography is simply a subset of the data acquired. Digital software today must be designed so all pertinent data can be presented to the patient on 1 screen, and the patient can easily follow along with the clinician as areas of disease are pointed out and a plan is formulated for proper oral care.
Summary
Imaging is central to any dental treatment planning process, and user-friendly software solutions must exist to leverage these data sets. Imaging software must allow one to interact with the data and not simply store and view data.
If software does not evolve, we will face data overload and not be able to effectively use the technologies available for improving patient care. Although these concerns and clinical needs for enhanced imaging software are real, they are not going unnoticed. DTX Studio by DEXIS and other software platforms are addressing the various pain points that have been described, so that clinicians can more effectively diagnose cases and plan treatment.
