Off the Ground

According to the American Dental Association (ADA), the integration of AI technology into dentistry isn't necessarily new; however, what is new is the expanded adoption of this technology.¹ Dental professionals across all specialties are increasingly relying on predictive software tools to assist in diagnosis, clinical decision-making, treatment planning, and prognosis prediction.² With AI technology integrated into digital imaging systems, dentists have the ability to use it to swiftly analyze radiographs to detect oral health issues, such as caries, bone loss, and infections.³ These AI annotations, which are available for viewing within the imaging system or practice management system, become part of clinicians' workflows, allowing them to consider AI-recommended treatment as they are diagnosing patients.³ "AI is just one of many diagnostic aids built into the examination process," says Eric Burgess, DMD, owner of the Burgess Center for Cosmetic Dentistry in Jacksonville, Florida. "In the end, providers need to use their own clinical skills and judgment to determine what needs to be done."

To understand how AI diagnostics are shaping the dentist-patient experience, one need only step inside the Manhattan, New York, practice of Sivan Finkel, DMD—The Dental Parlour. Finkel uses AI as a diagnostic aid that invites the patient into the process. Enter his examination rooms, and you'll see chairs paired with big TV screens that stream information and individual dental views for patients. Finkel explains the process with an example involving a patient who sought care for a vague pain in the lower left side of her mouth. When Finkel put her radiographs up on the screen, the surfaces of her teeth in that region appeared to be free of caries. To get an enhanced look, he applied AI-powered dental imaging software that is able to analyze patients' bitewing and periapical radiographs and detect up to nine different conditions on permanent teeth. The AI-generated overlay provided a color-coded, topographic view that revealed an irregular shadow that was close to the nerve. "The human eye can only detect approximately 40 to 50 shades of gray, but a computer can detect about 1,000," Finkel says. Thanks to the AI, rather than taking a "wait and see" approach, an immediate treatment plan was possible, heading off the spread of infection.

Burgess's cosmetic dentistry practice uses a diagnostic AI solution that is integrated into its practice management software and designed to aid dentists in diagnosis, treatment planning, and gaining case acceptance. "AI can help remove the mystery behind what may be causing dental pain and increase patient acceptance of treatment and next steps," he says.

Michael A. Scialabba, DDS, the chief clinical officer at 42 North Dental, a dental support organization (DSO) with more than 100 offices, recently implemented an AI solution that integrates with their practice management software as well. The AI automatically analyzes radiographs in real time, providing data to aid in clinical decision-making and patient case acceptance.⁴ Scialabba describes the technology as both amazing and humbling. "It is amazing because it explains pathoses clearly, accurately, and objectively to patients," he says. "It enables them to better grasp the concept than if they were simply looking at a radiograph, which is foreign to them. This helps patients understand potential issues and comply with treatment plans." The humbling aspect, Scialabba continues, is AI's ability to detect in such great detail. "I might look at old radiographs with the tool and find things that I previously missed," he says. "It can be an ego check, but then you realize that it will make you a better dentist in the long term." According to Scialabba, the rare instances in which his office's internet connection is unavailable are when he most appreciates the impact of AI. "I feel like I am back in the Stone Age when I look at radiographs without AI," he says. "It feels foreign."

Meanwhile, support for dentists, hygienists, and assistants for routine charting tasks can be provided by AI solutions with algorithms that emulate the entire process from start to finish. This includes combining pathological and nonpathological findings and streamlining many aspects of the workflow from offering treatment options to suggesting billing codes. In addition, auto-charting solutions have even been combined with dental informatics to convert the knowledge into risk assessments that help create efficiencies in the realm of insurance reimbursement.⁵

AI-enabled voice recognition and recording software can be used to automate the charting process, which not only mitigates the risk of infection associated with manual entry but also increases the accuracy of charting and offers other benefits as well. Using affordable recording devices, advanced AI technology can seamlessly capture dictated periodontal results as well as clinical notes and other practice correspondence. Front office team members can use it to dictate insurance claims, patient communications, billing notes, and more.⁵

Laboratories are utilizing AI as well. Megan Nakanishi is a third-generation owner of Nakanishi Dental Laboratory in Bellevue, Washington, which serves dentists nationwide. When her grandfather opened the laboratory 70 years ago, designs for crowns could take weeks. Even 10 years ago, using an analog waxing system, it required an 8-hour shift to produce about 20 designs.

Today, Nakanishi Dental Lab uses an AI-powered design program to design upper night guards and single and multi-unit monolithic molar and premolar restorations. The laboratory uploads the order and, once the design is ready, approves or modifies it.⁶ With this digital system, up to 10,000 designs can be produced in 10 minutes. "What once required melting a pot of wax, heating instruments, and using a stone model to form a crown's shape," Nakanishi says, "is now accomplished leveraging digital technology and strategic training."

According to Christian Yaste, DDS, owner of Ballantyne Dentistry in Charlotte, North Carolina, the segmentation of dental implants in cone-beam computed tomography (CBCT) images can also be accomplished via AI, which saves time while also increasing accuracy. "Efficiency in planning is so important, but so is accuracy," he says. "When you are segmenting implants manually, it can be time-consuming and exclusively relies on the skill of the dentist or the technician. AI accomplishes the task quickly and continues to become more precise as it learns more and more."

Nakanishi admits that her family's business has not always been an early adopter of new technology. "We have a lot of pride for the art that goes into our creations; we work to design the best crowns and the best dentures," she says. "We've always felt protective over the fact that this is our art." However, AI arrived at a time when the number of people retiring from the dental laboratory profession is outpacing the number of new entrants. And as dental technician education programs are increasingly experiencing shrinking numbers, and some are shuttering their doors, many laboratory owners are wondering where their future employees are going to come from.⁶ "We've been impacted by retirements and have had difficulties backfilling those roles, but AI offers an opportunity to close that gap." says Nakanishi. "We've seen how quickly it has made a difference." She adds that AI has helped her laboratory increase its sales by nearly 40% in the past 10 years without increasing its staff of approximately 60 employees.⁷

Beyond clinical dentistry, there are also AI-powered tools that can help automate scheduling, appointment reminders, insurance claim submissions, and digital payment methods. In addition, virtual assistants and chatbots, which use natural language processing algorithms, can offer real-time responses to inquiries 24 hours a day, 7 days a week.  This can reduce waiting times, streamline administrative workflows, and empower patients with information.³

Maryam Beyramian, DDS, MBA, co-founder and CEO of Westwind Integrated Health, emphasizes that integrating technology into her practice has been a priority since day one. "When we opened our practice, we started out paperless—the first to do so," she says. "Today, we're early adopters of AI, using the technology to enhance patient care and streamline our operations."

Westwind Integrated Health operationalized patient conversion across its dental and primary care services by integrating its internal platform with an AI practice growth platform. Beyramian found immediate value in the AI's quick alerts. "From flagging missed calls to scheduling patients, the technology is improving our patient workflow and customer service," she says. Beyramian notes that AI also helps her practice's call center by providing recorded calls, alerts for missed opportunities, and a scorecard for performance. "This helps us with our patient conversions, making sure we're available and appropriately staffed to meet our patients' needs," she says.

According to Jonas Bianchi, DDS, MSc, PhD, an assistant professor of orthodontics at the University of the Pacific's Arthur A. Dugoni School of Dentistry, closing the gap between dental and medical care begins with breaking down the silos of data management. To this end, AI can open pathways for the integration and analysis of multilevel data, such as medical and dental historical data, sociodemographic and clinical data, imagery data, biomolecular data, social network data, and more.⁵ "When mass amounts of dental and medical data are aggregated, standardized, stored, and processed, predictive insights for enhancing patient care are possible," Bianchi explains.

For example, using AI to review large sources of data could help to predict whether patients with certain specific characteristics were more or less susceptible to getting caries. When this type of standardized population data is available, it can help increase the precision of diagnoses and improve outcomes. Ultimately, the adoption of AI may offer the potential to integrate data management systems between dental and medical care, providing opportunities for more comprehensive, preventive, and holistic approaches to healthcare delivery.⁵

Jonathan B. Levine, DMD, owner of JBL NYC in New York, New York, believes that the successful adoption of AI into diagnostic and practice workflows is largely dependent on the dental professional's mindset. He notes that the adoption of new technologies and innovations in the profession of dentistry tends to be slow, and suggests that as leaders, "we need to get comfortable being uncomfortable."

Levine points out that the integration of AI will continue to be a guiding force and that patients support the advancements. "A huge shift in workflow practices from analog to digital is taking place at all levels of practice, including solo practices, multi-doctor organizations, and DSOs," he says. "Therefore, dental leaders need to build a culture of innovation that fosters a positive reinforcing loop of the four Cs—commitment, courage, capabilities, and confidence."

The COVID-19 pandemic created the right set of internal and external conditions for digital transformation across the industries of dental and medical care. AI-enabled solutions freed up staff time, reduced costs, and promoted patient engagement, making them attractive to many practitioners.⁸ As practices work to incorporate AI into their workflows, staff acceptance is key. Adopting solutions that easily integrate with practice management systems and remove repetitive tasks can positively influence staff acceptance. For Scialabba, the ease of transitioning and training staff was a selling point in his adoption of an AI platform. Being able to seamlessly integrate the program with existing cloud-based dental software made the implementation easier to "plug and play." He says that his staff trained during lunch and began using the program with patients that afternoon.

Some patients continue to have questions regarding the use of AI in diagnosis, including whether or not it is ethically sound to use and whether or not it is biased in how it functions. Burgess explains that once patients experience their dentist using the tools, many gain confidence in how it complements their care. "Some have even noted that they wouldn't go back to a practice that wasn't adopting the technology," he says.

Nonetheless, the opportunities and risks introduced by emerging technologies can be challenging to balance, and AI is no different. "Like any other assistive technology, it will make work easier and faster," says Larry Bodony, president of exocad America. "However, as with any new tool, we need to be careful because it is not always clear if the quality and/or predictability of an automatically generated result is acceptable. We focus on AI applications that provide substantial efficiency improvements, such as automatically generating a realistic lip line in a smile design solution, remembering that intuitive human interaction with the AI-generated result is required to ensure optimal quality."

Nakanishi recalls her laboratory ordering an AI design for an anterior tooth and receiving a design for a posterior one. "A computer isn't going to know when something's been done wrong," she says. "Knowledgeable humans who know what anatomy should look like are still needed."

Indeed, throughout dentistry, AI technology should always serve as a copilot rather than the solo guide. "I let the patients know that I'm not going to sit back and let my computer figure out what's wrong," Finkel says. "We look first with our eyes, and we make the diagnosis because we are the doctors. The technology is like another staff member offering a second opinion."

Florian Hillen, founder and CEO of the AI platform VideaHealth, acknowledges that dentistry has been hesitant in adopting emerging technology in the past but predicts that the profession will surpass other areas of healthcare in the adoption of AI in the next 5 years. He cites three reasons for this perspective, starting with job preservation. "AI does not eliminate jobs in dentistry because the treatment plan and the treatment itself will always be handled by a clinician," he says. "Some areas of medicine, such as radiology, are likely to experience significant pressure." Hillen's second reason is dentistry's integrated approach to pairing AI with practice management software. Practice management software for medicine takes a disparate approach that can lead to gaps as records travel between practices and hospitals. And third, Hillen credits the vast amounts of data organically collected throughout dentistry's workflow—from radiographs to various scans and more. "Unlike in medicine," he says, "data collection is already a routine part of the visit."

Yaste adds that, although AI has oftentimes been a source of fear in popular culture, dental patients tend to trust it because it is only used as an enhancement. "I compare our AI use to digital diagnostics in auto repair shops," he says. "We trust our mechanics more when they are confirming what the computer indicated. People do trust AI to some degree, as long as it is not making ethical decisions for us or performing tasks with no human supervision, which in dentistry, it is not."

The ongoing successful implementation of AI into dental practices will be dependent on the ability of manufacturers to continue developing applications that are easy to use and that maximize those data sets, and Hillen believes that they are up to the challenge. "Dentists are good at understanding their own needs," he says, "and it will be the responsibility of the AI companies to listen."

As with any new technology, the ultimate goal is to raise the standard of care. "I really believe that we can move the bell curve up and to the right, narrowing the band of diagnostic ability to move the standard forward," Burgess says. "The future of AI will be an awesome story to tell because now we are just scratching the surface. AI will drive more timely, efficient, and better care, and it will reduce the cost of dentistry."