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one Beam Computed Tomography and therthodontic Office of the Future

ntonio Magni

The use of technological devices has not always successfully increased the

efficiency of orthodontic practices. Often, new technology is introduced into

the practice too soon, effectively interrupting the learning process of their

older counterparts and hindering optimization. Consequently, the ultimate

goal of efficiency can easily become eclipsed by indulging into new orth-

odontic gadgets. Cone beam computed tomography can similarly get in the

way, if the users are not aware of such phenomena. In this article the author

relates how these can negatively affect efficiency, while explaining the role

of software interoperability for the ergonomics of the orthodontic practice.

Some suggestions on how to prepare for the future are provided. (Semin

Orthod 2009;15:29-34.) © 2009 Published by Elsevier Inc.

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he advantages of computerized equipmentwithin the orthodontic practice has been

mphasized through many applications rangingrom patient demographics to real-time three-imensional oral surface scanning.1 Over theast decades, the concepts of a paperless worknvironment and innovative imaging technologyave pushed orthodontic practices into an eraonsidered by some to converge with the com-uter screen.2 In this transitional phase, innova-ors of paperless technology have been attempt-ng a collaboration with paper charts, in whatrequently turned into an inefficient use of bothystems. In essence, no established structure ex-sts yet that defines how to optimize the collab-ration between orthodontic technologies.3,4

The task of keeping up with the latest inno-ations becomes more and more straining eachear, as can be observed by the constantly grow-ng orthodontic trade shows. The sensation ofeing overwhelmed by technology is known toany in the field: one has not had the chance to

ully unleash the power of their present elec-ronic instrument, yet one is strongly tempted to

From Cogent Design, Inc., Rossiglione, Italy.Address correspondence to Dr. Antonio Magni, Cogent Design,

nc., Cascina Ciapee, Via Valle Berlino 151, 16010 Rossiglione,E, Italy. E-mail: afm@antoniomagni.com

© 2009 Published by Elsevier Inc.1073-8746/09/1501-0$30.00/0

doi:10.1053/j.sodo.2008.09.005

Seminars in Orthodontics, Vol 15, N

urchase a new one. Cone beam computed to-ography (CBCT), for example, has probably

een one of the most revolutionary medical in-ormatics innovations in the field of dentistry ofhe past decade.5 Thanks to its lower costs andower dosage (compared with regular CT) it has

ade three-dimensional (3D) imaging a tangi-le reality for the dental field. If widely used, itill affect a very large area of the orthodonticractice in the future, from visual treatment ob-

ectives (VTO) to digital casts to 3D cephalomet-ic analysis and incidental findings.6 However,he previous technology (2D digital x-ray imag-ng) has not worked out all of its problems yet.ssues related to comparing images produced byifferent devices7 (uneven magnificationnd/or distortion) and interoperability still re-ain unanswered for most users.As we believe simple observation of man-

ind’s past and present behavior to be an effec-ive prediction method, this trend can be ofreat evidence to foretell the future of orth-dontic technology. Therefore, if the consumerarket is constantly fed with new gadgets, older

nes will rapidly lose their monetary value, mak-ng them affordable to an ever increasing num-er of users. So what will happen within therthodontic practice?

There will be interoperable gadgets almosteverywhere, which will optimize time manage-

ment and increase patient care, making use of

29o 1 (March), 2009: pp 29-34

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30 A. Magni

next generation technologies such as nano-technology8 and quantum computers.9

Less time will be spent on erratic computerbehavior caused by unstable systems. Operat-ing systems are already increasing reliability(Mac OS X is very stable, Windows Vista seemsa major improvement over its predecessors,and Linux is becoming extremely popular,because of its price and stability). (Please notethat absolute stability is probably utopia: It isbelieved to be mathematically impossible todevelop a completely bug-free software.10,11)User interfaces will be easier to use, and morepleasurable to work with.Time and money will be better managedthrough an increased awareness and con-sciousness, driven also by the constantly risingprice of raw energy. The need to save powerwill develop from purely environmental intoan economical reality.The orthodontic practice and their memberswill depend on computers to such an extentthat, if they fail to operate, practice activity willcome to a full halt.The orthodontic practice will have the capa-bilities of being more efficient by making useof digital tools such as digital photography,digital 2D and 3D radiography, and other nextgeneration imaging modalities (chair-side oralscanning 3D in motion1) and all other gadgetsstill to come.Orthodontics will spread all over the world.12

If we look closely, many of the above predic-ions are somehow linked with ergonomics andnteroperability, which shall be discussed in fur-her detail.

rgonomics of the Future

n this section the importance of understandingfficiency at the deepest level, and how a super-cial understanding can actually lead the indi-idual toward inefficiency is discussed.

The term “ergonomics” is defined to be “thetudy of people’s efficiency in their working en-ironment,”13 where one of the definitions ofefficient” is “preventing the wasteful use of aarticular resource.” The orthodontic field, asost medical fields, is striving for optimized pro-

esses in its working environment in an attempt

o reduce wasteful use of time, energy, and other m

esources. The goal is to make processes as effi-ient as possible and the underlying reasons areften taken for granted, but are worth analyzing.

When thinking about this concept, question-ng started about the ethical value of efficientystems. We believe happiness is the universaleed of mankind, so the thought process was: “Is

t really necessary, after all, to be all that effi-ient? Will it really make us feel happier? Whatre we going to do with the extra resources?”onsequently, through an informal survey someossible ways to use the resources gained from

ncreased efficiency was collected:

Treating more patients.Adding new services to the practice.Renovating the working environment.Increasing competitiveness.Investing time outside of the workplace (fam-ily, hobbies).

At first glance, none of these seem to addressappiness directly. On the other hand, they doppear to be quite “positive” goals. For instance,n an ethically ideal world, one treats more pa-ients to help society by increasing patient care.hinking about today’s society though, eagernessould cause the principal motivation to be to in-rease one’s income. A similar reasoning could bepplied to most of the remaining points as well.he conclusion was that there is something incom-lete with this view of efficiency; there is some-

hing missing.Making the assumption that the ultimate goal

f practicing our profession is to help us (andhose around us) lead a happier life, the sugges-ions of Piehler14 seemed to provide the missingink between efficiency and its existential rea-ons. He suggests investing the time gained byncreased efficiency into face-to-face time withhe patients, creating a more pleasant and relax-ng working environment. After all, generatingegativity is an expensive process that drainsaluable energy (for example, time and concen-ration spent trying to convey anger in words viamail). Technological gadgets and their prom-sed increased efficiency lose significance, if is-ues such as stress, tension between staff mem-ers, patients and practitioners are notddressed, because by themselves, they do notead toward the universal goal of happiness.

Empirical evidence shows us that it is a hu-

an trait to tend to indulge in materialistic dis-

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31Office of the Future

ractions, because these can cause immediateleasurable sensations connected with moreontrol over the environment they are intendedo work in. Because of the impermanent charac-eristic of all sensations, they are bound to dis-ppear, often leaving an unpleasant sensation ofraving behind. The most common conse-uence is indulgence into the purchase of a new,lightly better object, which, in turn, triggersew impermanent pleasant sensations of controlnd power, and the cycle continues. It takes aery balanced mind to remain equananimous toll these sensations and break out of this cycle.

Industry is well aware of this, and does notesitate to feed the demand of the consumer by

ntroducing new gadgets on the market in a veryontrolled fashion: when a new technology be-omes available, it does not enter mass produc-ion until the old one has exhausted its profits.15

his time frame is therefore based on the arisingnd passing away of the above-mentioned sensa-ions of the consumer, rather than on the effi-ient use of the product in one’s working envi-onment. (We suggest that the reader keep inind that the intention of this article is neither

o condemn nor to praise this schema, buterely to observe it, and to try to predict the

irection we, as technology users, are headedoward.)

Piehler’s suggestions of concentrating on self-wareness, smiling, and establishing more hu-an and friendly interactions with the patients

nd staff, addresses exactly the heart of the prob-em: the goal is not to focus on (as one may beempted) the materialistic distractions, but onur ultimate goal of happiness.14 Therefore,here is nothing inappropriate or inherentlywrong” with the above-mentioned list, as longs one is constantly aware that it has been set toulfill the universal need of happiness. Thiswareness is what will keep the individual in theuture from falling into inefficient use of tech-ology.

Every year there is an increasing number ofnvited speakers at medical and orthodontic con-entions who deal with issues related directly toappiness (like stress), and most of them focusn self-awareness. Today, many techniques arevailable to help increase self-awareness16,17: ailigent practical approach is the quickest way

oward a more sensitive mind, which will allow to

ore quickly identify and solve the problems f

ncountered during everyday life, includinghose related to ergonomics. Based on this ob-ervation, our vision for the orthodontic officef the future is a peaceful practice, with charac-eristics such as:

Patients less hesitant to pay, that is, reducedlate fees.Less arguing between staff members, that is,increased collaboration and efficiency.Fewer complaints from staff and patients, thatis, more time spent toward work instead oftoward negativity (such as generating longemails and letters of complaints).Patient leaves practice happier, that is, in-creased referral rate.Increased communication between patientand staff, that is, reduced premature treat-ment ending due to misunderstandings.A wholesome service to society, that is, some-thing to be proud of, which keeps the individ-ual (doctor, staff, and patient) peaceful andhappy.

The reader should not be discouraged by theact that reaching these goals requires a greatmount of effort: as one progresses toward self-wareness, initial results appear immediatelyroviding motivation for further development.esides, when one works toward a goal one is

ully convinced of, be it easy or extremely chal-enging, it is very easy for one to feel good aboutneself.

nteroperability

s stated above, new, more enhanced models oficroelectronic software driven tools get intro-

uced into the market before the average con-umer has had time to unleash the full power oflder models.15 The consumer is tempted to

ndulge in promising features, but how will theew gadget cooperate with the existing elec-

ronic inhabitants of the orthodontic practice?he consumer might soon realize that interop-rability between these devices is not well estab-ished.3,4

Interoperability is the ability to exchange ando make use of exchanged information. Theower of medical informatics lies in the ability touickly search through large amounts of data,nd to be able to manipulate those data in dif-

erent ways, without having to manually dupli-

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32 A. Magni

ate them. In other words, the increase of effi-iency in medical informatics lies in its capacityo be interoperable. This will not materializentil flawless patient data interchange acrossedical fields becomes a reality.Today, orthodontic software interoperability

as found limited implementation.3,4 Some soft-are systems allow images to be exchanged, mak-

ng use of existing standards such as digital imag-ng and communication in medicine (DICOM);ther companies collaborate and developbridges” (an application that creates a bridge foratient data between two different software prod-cts) that allow their software to work together. A

ew institutions are using a medical informaticstandard called Health Level Seven (HL7),16 butostly only an older version of it. In general, not

oo many software products are compatible withhese standards.

The use of already developed clinical infor-atics standards has been limited to observation

nd prototyping by vendors and experimenta-ion in academia, mainly because the use ofroprietary design maintains the vendors’ com-etitive position in the marketplace.3 A standardnly gains commercial value once it has beenidely implemented. This explains why vendorsre reluctant to implement a new informaticstandard. What is often ignored is that releasinghe consumer’s data from bonds to a specificoftware (which is what happens when a softwaretores patient data in a public, standardized for-at) means more freedom of choice and pur-

hase, therefore greater chances for consumerso invest in various different software products,ncluding their own.

Currently we see increasing interest in thesetandards owing to current US federal govern-ent initiatives in health information interoper-

bility,19 following a trend already present inther regions like Europe (where there isreater government involvement in health carerograms).

If we accept the assumption that computerrograms should improve patient care by mak-

ng processes more efficient, inability to ex-hange clinical data seamlessly is unacceptable.hese issues are being currently addressed by

he American Dental Association (ADA) Stan-ards Committee for Dental Informatics (SCDI)orking Group (WG) 11.6 and DICOM is WG

2.1 through the development of a standard for d

he electronic orthodontic patient record. A firstroposal for defining digital cephalograms in aell-established medical imaging format (DICOM)as been published by Magni in 2006,18 and it isurrently being revised and approved by theICOM committee. tops (developers of tops-rtho™ and topsCephMate™) is directly partic-

pating in this task by supporting the author inis efforts. Next steps include: the definition andpproval of use case scenarios for the utilizationf orthodontic digital data, involvement with theL7 community and the origination of a docu-ent that clearly specifies how DICOM and HL7

hould be used when defining electronic orth-dontic patient records.3,20

We expect initial standards to be ready formplementation within the next few years. Onhat account we strongly encourage both orth-dontic software developers and consumers to

oin the development efforts today (visit http://ww.antoniomagni.org/panio for more infor-ation) to help define the technological aspects

f the orthodontic office of the future.

one Beam Computed Tomography

maging devices have always constituted an im-ortant step in the patient’s flow of an orth-dontic practice, as they produce two centralools for the diagnosis and treatment of an orth-dontic case21: photographs and radiographs.s a result, any change to these devices will most

ikely require a fundamental change in the pa-ient’s workflow, rendering it an expensive task.

Computed tomography (CT) offers 3D imag-ng, that is, the ability to work on the patient’sirtual body (the 3D images produced by CBCTachines) and to recreate any set of 2D images

rom it, without the need to further irradiate theatient. The radiation dosage and the size of aonventional CT device are too high to justify itsse in dentistry. Over the past decade, a simpli-ed version of the CT scanner, called cone beamT (CBCT) has been introduced into the mar-et, offering considerably lower radiation dos-ge, costs, and space requirements. For this rea-on, CBCT seems to have had greater impact onhe dental field than other technological gad-ets have. While it has been proven to improveiagnosis and treatment outcome results for sur-ical procedures,22 no clinically relevant evi-

ence has been recorded for a pure orthodontic

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33Office of the Future

reatment. In such cases, it is not advised toake use of CBCT imaging, as this would not

ollow the “as low as reasonably achievable”ALARA)23 principles: CBCT exposes the pa-ient to considerably more (about 4-5 times24)osage than a regular 2D radiograph, be it aanoramic, lateral, or postero-anterior view.

Yet the desire to break loose from the old 2Dechnology and its related problems (mainly

agnification and distortion7) seems to exist. Inact, one of the major advantages of CT technol-gy over regular radiography is the possibility toccount for distortion caused by radiographicagnification. Research is currently being done5

o try to establish if CBCT can indeed providemproved diagnosis and treatment for orthodonticases. Specifically, it is hoped for CBCT to cast arighter light on less predictable treatment out-omes.

Summarizing, CBCT is a large and expensivelectronic device, which comes with all theromising features and temptations discussedbove. It requires interoperability with manyther devices, many of them lying outside theental field altogether. For this reason, mostBCT devices save their images in an alreadyxisting medical digital imaging format (DI-OM standard), which requires orthodonticnd dental related software to also be able tonderstand DICOM. Therefore, CBCT scannerso have an important role in the dental field.ot only do they make 3D imaging affordable,ut they also provide an incentive for the divul-ence of software standards.

onclusions: Orthodontic Officef the Future

he author believes that technology will bringreat power to the future orthodontic office,hile interoperability will make it much morefficient. One should be prepared to make wisese of these upcoming tools; otherwise they canasily transform into obstacles. To do so, theuthor advises learning more about standardshrough the ADA SCDI, DICOM, and HL7 com-

unities and Web sites and by constantly askingbout standards when communicating with soft-are vendors. The reader will not find a com-lete implemented orthodontic electronicecord standard yet, but the imaging software

hould at the very minimum be able to import p

nd export DICOM images. The knowledge oftandards could be divulged among colleaguesy actually using them whenever possible15: thisould also prepare the user for standards, forhen they will become mandatory (for certain

asks).In addition, it is advised to pay particular

ttention to the user interface when consider-ng the purchase of new technology. It is com-

on for a product to be a great invention, buto ship with a very poor user interface.25 Onehould not underestimate the importance oft, as it provides the primary communicationetween the human being and the machine, and issed every single time the machine needs to beperated.

Efficiency can similarly become an obstacle, ifot taken seriously.

Increasing one’s own concentration and per-eption skills are considered to be the most ef-ective path toward a successful and productiveractice. High concentration can reduce suscep-ibility to distraction, while an increased percep-ion can help spot a problem or a distractionefore it actually arises. Developing these skillsn one’s own can be a tedious task (it may

nvolve considerable change in our behavior);elpful self-awareness programs are becomingore popular every day. With a positive and

atiently insisting attitude, any goal can beeached.

Courses and programs that teach how to in-rease individual skills such as concentration,wareness, perception, and patience are avail-ble from various sources involving simple uni-ersally available techniques16,17 as well as morepecific methods based on rituals or physicalctivities. It is advisable to experiment with a fewnd choose one that is most compatible with thendividual.

Time should be taken to evaluate how tech-ological gadgets are being used in our prac-

ices. Are they helpful, or are they actually ob-tacles? Are they being used properly? Howuch time is being saved? Is this extra time put

o good productive use? What can be done toake the work environment more peaceful and

armonious? It is believed that if one is able toeep focused on these issues, one will be pre-

ared for any developments in the future.

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