In a brief series of posts, I offer some predictions for the directions that dentistry will take in the coming decades. Part one:
All imaging will be 3-D and very high resolution. In our own office, we've already transitioned from those little "analog" X-ray films to 2-D digital. There are so many advantages to this. We can manipulate and work with our images to better diagnose our patients. The images are larger and of better resolution than the analog ones were- and kinder on my eyes, which now have behind them more than a quarter century of making decisions for patients based on varying shades of gray...
At the present time, 2-D digital X-rays are the best way to see decay between teeth. These cavities can be thought of as "flossing cavities", or perhaps "not-flossing cavities", because they occur under the place where teeth meet, where we can clean best by flossing. These cavities look like little dark triangles, bitten out of the light gray enamel, just where the teeth touch each other. The question in early ones always is, "Is this deep enough to require a restoration, or is it just a bit decalcified, and not yet a cavity?" Here are some of these dark areas that have just crossed over the threshold into being cavities:
Then we have challenges that are presented by the overlap between teeth on images that results from crowding and misalignment. In this next film, we have a hard time reading what, if anything, is going on between the two upper molars. We also have difficulty determining if there is decay under the old silver amalgam restorations, which are the bright white objects. (Well, the bright white objects except for the one shaped like the letter "a"...) Yet the lower teeth in this film show up perfectly well. If we were to try for an angle that better captures the upper situation, we'd miss something on the lower. It's a catch-22.
While the tooth on the far right in the next image has a cavity that deserves its own Zip Code, we still face decisions of whether such a tooth can be saved with advanced treatment. Perhaps an extraction and implant ("titanium doesn't decay" being a defensible mantra) would be more appropriate. Many times in my career I've decided such issues by intervention, meaning anesthetizing my patient, excavating decay, initiating root canal treatment, and deciding if I can save the tooth when I've seen what's left. While I keep my fees low until the issue is decided and my patient commits to a course of treatment, how much better it would be if we could image the tooth in 3-D and with a voxel size of hundredths of a millimeter. I could look at the image on the computer with my patient by my side and we'd decide on treatment without any invasive procedure being done.
What I look forward to is this: that all of our images will soon be very high resolution 3-D. We will be able to virtually take teeth out of the arch and spin them around and look at them from all sides. We will be able to look at cross sections and evaluate whether early lesions are decay or not with an extraordinary degree of certainty, even in situations where there is overlap in the actual patient's mouth. We will be able to manipulate images and better diagnose and evaluate all oral disease, including root canal infections and periodontal issues. Planning dental implants will become a matter of precision placement, where injury to critical structures in the jaws is avoided with total certainty. Post-operative radiographic evaluations of restorative, endodontic, implant and other treatments will be orders of magnitude better than they are now, and will provide superb legal documentation. The list of benefits is almost endless...
The application of this technology to periodontal (gum) disease diagnosis is also exciting to think about. We will have a better pre-operative understanding of angular bone defects like these:
This process of adopting the innovation of 3-D radiographic imaging in denstistry is already starting. Our periodontist and oral surgeon friends have iCAT and other scanning devices and our patients benefit tremendously when periodontal and dental implant procedures are planned. In addition, some endodontists (root canal specialists) are using the Kodak K9000 3-D dental imaging device to diagnose and evaluate their treatments in 3-D. I've listed the 0.005 - 0.038 mSv radiation exposure in http://rickwilsondmd.typepad.com/rick_wilson_dmds_blog/2010/05/sieverts-they-used-to-be-so-rad.html, which lists the exposures from a large array of common medical diagnostic procedures.
These are from an iCAT scan of me, by the way, done by my friend Thomas Kohler D.D.S.:
And yes, "Golden-Jaw" would be a very cool nickname for a dentist...
Perhaps the most serious challenge of all in dentistry is to accurately diagnose bone cancer and bone metabolic disorders like Paget's disease. Scanning in 3-D at high resolution for very minimal radiation exposure will be a tremendous benefit to our patients.
So, I look forward to the day, which will no doubt be here soon, when 2-D X-ray images are a niche, a thing of the past, with all the quaint 80's-era functionality of the fax machine and cassette-based Walkman. Back then, you could still send information instantaneously and listen to a personal music library- but we do these things much better today with the digital storage and transfer of information.
Next up: 3-D optical scans as an innovation that replaces physical impressions of teeth.