DIGITAL DENTISTRY: THE NEW STATE OF THE ART — IS IT DISRUPTIVE OR DESTRUCTIVE?
ABSTRACT
Objective. Summarizing the new state of the art of digital dentistry opens exploration of the
type and extent of innovations and technological advances that have impacted – and improved
– dentistry. The objective is to describe advances and innovations, the breadth of their impact,
disruptions and advantages they produce, and opportunities created for material scientists.
Methods. On-line databases, web searches, and discussions with industry experts, clinicians,
and dental researchers informed the content. Emphasis for inclusion was on most recent
publications along with innovations presented at trade shows, in press releases, and
discovered through discussions leading to web searches for new products.
Results. Digital dentistry has caused disruption on many fronts, bringing new techniques,
systems, and interactions that have improved dentistry. Innovation has spurred opportunities
for material scientists’ future research. Significance. With disruptions intrinsic in digital
dentistry’s new state of the art, patient experience has improved. More restoration options
are available delivering longer lifetimes, and better esthetics. Fresh approaches are bringing
greater efficiency and accuracy, capitalizing on the interest, capabilities, and skills of those
involved. New ways for effective and efficient inter professional and clinician-patient
interactions have evolved. Data can be more efficiently mined for forensic and epidemiological
uses. Students have fresh ways of learning. New, often unexpected, partnerships have formed
bringing further disruption — and novel advantages. Yes, digital dentistry has been disruptive,
but the abundance of positive outcomes argues strongly that it has not been destructive.
1. Introduction
Digital systems are ubiquitous in our lives. Interconnectivity has increased 1125% since 2000;
in June 2019, 57.3% of the world’s population owned a cell phone with ownership reaching
over 80% in Europe, and North America [1]. With digital assistants, your voice is their
command; answering questions, ordering food, arranging a car to drive you, translating spoken
language into different languages, comparing product brands for you, and much more [2].
Beds can automatically adjust your position if you snore [3]. Sensors in babies’ diapers can
track babies’ activities to alert you when the diaper needs to be changed. Nearly every device
in your home, from window shades to pet feeders, can be controlled digitally with a push of
button or voice control [5]. It is no surprise, then, that digital systems are becoming more and
more commonplace in dentistry.
2. Early drivers of digital dentistry
Historically, digital advances had three foci: CAD/CAM systems, imaging, and practice/patient
management systems. CERECTM, the first commercially available in-office CAD/CAM system,
made possible delivery of same-day restorations [6]. A laboratory-based system, PROCERA TM,
was introduced at about the same time [7]. Together, these systems catalyzed both evolution
of new materials [8] and development of multiple other CAD/CAM systems [9].Early drivers in
imaging include both the intra-oral imaging systems integral to the CERECTM system and
evolutions in digital radiography. First introduced in the late 1980s, digital radiography has
transformed the field, enhancing image quality, evolving from phosphor plates to solid-state
detectors, cone beam computed tomography (CBCT) and new generations of intra-oral
scanners. Practice management software makes possible capture of patient demographics,
scheduling appointments, interaction with insurance companies, initiating and tracking billing,
and generating reports. In parallel, electronic patient records, digital version of patient-
centered clinically oriented information, motivated changes in tracking patients’ health,
facilitating quality of care assessments, and mining data for research, including evaluation of
efficiency and efficacy of clinical procedures [11].In parallel, other technologies influenced and
enabled innovations in digital dentistry, often at a remarkable pace. While not a
comprehensive list, these technologies undoubtedly include sensor miniaturization, artificial
intelligence, augmented and virtual reality, robotics, 3D printing, telehealth, big data,
interoperability, internet of things, nano-technology, quantum computing, biomedical
engineering, cost of data storage, connectivity, and others. Many are technologies we never
imagined and words we didn’t even know20 years ago.
3. State of the art of digital dentistry — now and in the near future
Unquestionably, dentistry today is changing. To some degree, digital systems permeate and/or
enable almost every-thing in dentistry (Fig. 1). Modern systems are user- and patient-friendly,
versatile, and clinical assets [12]. While the scope of digital systems is immense, those
discussed below focus primarily on those that have implications and opportunities for
developments and innovations in material science.
3.1.1. Intraoral scanners
With on-screen images, explaining treatment opportunities to patients is simplified. Patients
appreciate the more comfortable data-acquisition process. Space-demanding plaster
casts/models are replaced by easily archived digital files. Data can be replayed at any time for
a host of different reasons. Drawing from comprehensive data for the 11 intraoral scanners
featured at the 2017 International Dental Show and available updated information from
suppliers, scanner features are summarized below [13–27]:
• Time required to scan one full arch: 1–10 min (with the majority at 1–3 min)
• Tooth coating necessary: not needed for 8 of 11
• Capture of occlusion possible: all systems
• Capture images in color: 4 of the 11 capture in color; 7 capture only in black and white
• Enable shade selection: possible for 3 of the 11; 6 include color capture of image
• Scanner wand weight: 2.5–17.6 ounces; 6 of the 11 are under10 ounces
• Scanner dimensions: 0.4–2.9 square inch in the tip area; 8–10-in. length
• Depth of field: direct contact to 15−18 mm; one images from7 to 22 mm.
• System configuration: carts, portable (hand-held/tablet), integrated into the dental chair;
multiple configurations are available from most manufacturers
• Wireless connection: available in most
• Open/closed architecture: all systems have open architecture; 2 also offer closed
architecture
Accuracy and trueness between scanned data and reference data have been comprehensively
studied. Results, even with scanners that are earlier designs, show small differences between
intraoral scanned data, extraoral scan data, and data from conventional impressions/models
though all are within acceptable limits for clinical use [28–31]. Not unexpectedly, sharp
corners, powder coating, and long cross-arch spans can influence the accuracy [32]. Scan
pattern may influence accuracy [33] or not [34], depending on study design and which
scanners were used.
The major concern, however, is whether or not the restorations produced based on intraoral
scan data are equal to those produced from conventional impressions. Most studies found no
difference in margin fit of restorations produced by these two approaches to data acquisition
[35–43]. Precisions of internal fit of conventionally and digitally imaged cross-arch prosthesis
were slightly worse for the digitally produced but still were deemed to be ‘not beyond the
range of clinical prestige’ [44]. At least one investigation reports better marginal fit with digital
scans although the differences are both within conventionally acceptable limits [45]. Digitally
fabricated 3-unit ceramic frameworks fit better than conventionally fabricated metal
framework [46]. Unfortunately, it is difficult to definitively compare results across different
studies. Between April and July 2017, 2093publications appeared in peer- and non-peer
reviewed sources. Of these, 183 had full text and only 34 contained
3.1.2. Laboratory scanners
At least 20 laboratory-based scanners are currently available, capable of scanning either stone
casts or impressions. All have accuracies of at least 15 m and are widely used in office-
laboratory workflow.
3.2. CAD/CAM systems
CAD/CAM systems revolutionized designing and fabricating restorations, models, and other
appliances. Pioneering efforts of the early systems could fabricate only inlays. Now, there
seems to be no limit in the types of restorations that can be produced, ranging from simple
inlays to digitally designed and fabricated full dentures, orthodontic appliances, study models,
implant-related components, and both simple and complex surgical guides [9]. Introduction of
open architecture has redefined how and where data flows to design to fabrication, creating
ingenious pathways (discussed below). In 2019, there were 252 CAD/CAM related exhibitors at
the IDS meeting [53]! This precludes creating a comprehensive list of CAD/CAM systems.
Instead, innovation in design prowess and shift from subtractive to additive manufacturing is
the focus of the following discussion.
3.2.1. CAD/Design software enhancements
Integration of data from multiple sources in combination with improved user-interface and
CAD software capabilities has opened important options. Software modules now include
robust esthetic enhancements, including smile design, tooth form libraries, color matching,
and tooth placement for dentures. Other enrichments integrate jaw tacking to improve and
automate components of dynamic occlusion [9].Digital smile design integrates digital
photographs of the face and software analysis to assist practitioners and lab-oratory
technicians in creating and planning a course of treatment, providing a virtual simulation of the
final esthetic results. This is particularly valuable in complex, multidisciplinary restorations. It
enables and facilitates communication between clinicians and the laboratory. Importantly, it
also is critically important in pretreatment discussions with patients, involving them in choices
that affect esthetics and establishing realistic expectations the patient has for treatment
outcomes [54–58]. Interestingly, some investigators report that other general-use image-
processing software, not integrated into CAD packages, yield similar or more comprehensive
smile analysis [59, 60].Tooth form libraries provide general tooth form and proportions,
enabling partial automation of restoration design and speeding digital ‘waxing’ [61]. Both
tooth form and color are critical to patient satisfaction. Digital photographs can be calibrated
for color and white balance and then mapped onto the virtual image obtained by intraoral
scans [62, 63]. Virtual teeth models with more detailed photograph-based color information
facilitates shade matching and enables patient-clinician co-decision making about the final
restoration [62]. The impact on final shade selection of intraoral scans captured in color may
be able to eliminate the integration of photographic information, but this has yet to be widely
reported. It is unclear that CAD software can automatically compensate for shade variations
caused by manufacturing processes, cement choices, or underlying tooth structure. Occlusion
is a critical factor in restoration design and longevity as well as patient satisfaction. Jaw
dynamics captured by cone beam computed tomography (CBCT) or an intraoral scanner create
a virtual articulator [64, 65]. Capturing the full range of static and dynamic jaw movements and
occlusion, the data can be integrated with smile design, computer-assisted implant planning,
and digital maxillofacial surgery planning [65]. Unfortunately, integrating the data from
multiple sources is not yet completely seamless, requiring interactive transfer of files between
systems along with user-interactions for superimpositions [65].3.2.2. Additive manufacturing
Additive manufacturing, commonly referred to as 3D printing (3DP) is now a completely
integrated option in CAM hardware, providing an alternative to subtractive machining
(milling).The most unique factor in additive machining is the flexibility of design. No longer
must a solid block be the starting point for fabrication. Instead products are created layer-by-
layer, enabling a high degree of geometric complexity. Now, products can be built with
different internal geometries as well as the desired topographic geometry. It is not yet clear
that innovation in design of dental prostheses is capitalizing on this opportunity [66].Although
7 different 3DP technologies are available [67–70],four are most commonly used in dentistry:
stereolithographic (SLA), digital light processing (DLP), material jetting (MJ)and material
extrusion (MD) although others are also being explored [69,71,72]. INVISALIGN TM was one of
the first to lever-age 3DP printing models with successive tooth positions upon which
orthodontic aligners were fabricated [73]. Today, 3DPcan deliver an exceptionally broad range
of dental ‘parts’, including everything from simple models, wax forms, tooth colored
temporaries and surgical guides, to more complex long-term metal and ceramic prostheses
and digitally manufactured full dentures [9,74]. Depending on the system, material choices
include glass ceramics, cobalt chromium, composites, PMMA, Resin/polymers, wax, titanium,
zirconia, with ever more choices becoming available with new material innovation [9,71].The
quality of 3DP products is at least equivalent to those produced by more conventional
methods [75,76]. Among a host of specific studies, 3DP interim crowns fit better [75, 76], drill
guides are accurate to within 0.25◦of planned implants [77]; occlusal splints had comparable
polished surface and similar wear [78]. Trueness of external surface, intaglio sur-face, marginal
area, and intaglio occlusal surface of 3D zirconia printed crowns was ‘no worse than the
corresponding milled crowns’ [79]. Custom-made templates and craniofacial pros-theses yield
good esthetics and better prosthesis fit than traditional methods [80].One particularly
interesting in-vivo study reports degree of comfort and satisfaction for twelve patients given
two sets of removal full dentures fabricated with CoCr bases, one 3Dprinted and one
fabricated with conventional methods [81].The patients rotated wearing the dentures. At the
end of the study, only one patient preferred the conventional denture and three had no
preference. The 3DP denture bases, though identical in material and design, were harder,
denser, and had better microstructural organization. They had better clasp retention and
denture stability due to higher yield strength and ultimate tensile strength.3DP plays an
essential role in diagnostics and treatment planning as well as enhancing patient
communication, skills training, and maxillofacial surgery [82, 83]. Low-cost printers may be a
realistic alternative for in-house production. They can produce clinically acceptable provisional
crown and bridge restorations [84], full arch models [85] and digital copies of plaster
orthodontic models [86]. These create realistic models with sufficient dimensional integrity for
various applications [82]. They are also successful in creating facemasks for face transplant,
assuring donor resemblance without risk to the allograft [87].Importantly, adding 3DP to digital
dentistry opened the door to new material innovations. To date, after a comprehensive review
by Galante et al., it can be argued that additive manufacturing of ceramics for dental
applications remains understudied [71]. Another reviewer’s search relating to fabrication of
dental implants by additive manufacturing found1322 relevant papers but only 13 ‘qualified’
for the systematic review. One could conclude that a standard methodology for evaluating
efficacy of additive manufacturing is clearlyneeded.3.2.3. Workflow with CAD/CAM While the
functional components of data acquisition, design, and fabrication have not changed with
modern CAD/CAM systems, the choices in how work flows through the process has changed
dramatically. Open architecture of digital systems created new opportunities. Rather than
closed systems where all the functional components were incorporated into a CAD/CAM
system, now functional components from different manufacturers can be selected and linked
by the user. This permits the processes of creating restorations tobe distributed to best meet
the interest, capabilities, and skills of those contributing to fabricating dental components. Fig.
2 demonstrates how work may flow through different channels, each of which is capable of
producing high quality restorations/prostheses. Digital workflow has shown that the time from
data acquisition to final product is shortened with digital workflow with greatest savings in
laboratory time [88, 89].
4. The digital virtual patient as an enabler
The integration of data from multiple digital technologies changes the scope of what is
possible. The digital patient data is vital in computer-assisted surgery/dynamic surgical
navigation, robots performing dental procedures, CAD/CAM and new approaches to one-
appointment restorations, and tissue engineered scaffolds. The digital patient is created by
integration of facial data from photographs or various 3D tracking devices, radiographic
information, intraoral image data, as well as other digital data that may be appropriate (e.g.,
CBCT scans, etc.). Using the virtual patient as a platform, enables development of a digital
treatment plan, on-screen design and simulation of procedures such as design of restorations,
surgical navigation for implant placement or craniofacial (and other) surgeries, and virtual
models for education and communication with a patient [90–93]. Creating the virtual patient
reduces errors that can be introduced when using conventional approaches, decreases time
required for planning, and increases intuitive-ness [91, 94]. In addition, the virtual patient
permits clinicians and technicians to digitally model and evaluate multiple con-figurations and
solutions more easily than with conventional approaches which may introduce damage to
models, have limited breadth of 3D data available, and require tedious manual manipulations.
In orthognathic surgeries, for instance, planning with the virtual patient allows high precision
and optimization of each treatment phase resulting in more accurate orthognathic results
[95,96]. If desired, CAD/CAM system scan directly design and fabricate prostheses, surgical
guides, models, or other structures.
4.1. Computer-assisted surgery/dynamic surgical
l navigation Computer assisted surgery is yet another of the remark-able opportunities enabled
by digital technology. With this approach, a navigation system, similar to global positioning
systems, tracks the position of a surgical device in real time (e.g., endodontic file, implant
placement, scalpel). The device position is projecting onto the digital image of the anatomic
area of interest, providing guidance to the clinician/surgeon, helping him/her in real-time to
follow the anticipated path-ways and recognize possible interference with tissue adjacent to
the treatment area. Today’s most commonly used optical tracking systems are based on
capturing the position of a series of light emitting diodes mounted on a surgical device. In
2017, the United States’ Food and Drug Administration approved a computerized navigation
system (YOMITM) which provides robotic guidance to augment clinician’s skill and precision for
implant surgery [97].Details of using dynamic surgical navigation dental procedures, including
trauma and facial reconstruction, have been described by LANDAETA-QUINONES, et al. [98].
Site-specific cranial-facial surgeries have been detailed by GUO and CAI et al. [99,100].In a
systematic review, positioning accuracy of both dental implant horizontal apical and angular
deviation was shown to improve with surgical navigation [101]. Augmented reality navigation
results in smaller horizontal, vertical and angular errors in central incisors and canines than
was achieved with traditional 2D image-guided navigation [102]. In endodontics, surgical
navigation is safe, minimally invasive for root canal location and prevention of technical failure,
especially in anterior teeth with pulp canal calcifications [103].In computer-assisted
maxillofacial surgery, positioning accuracies have been reported to be <1 mm in an ideal
setting and between 2 and 4 mm in a real-life surgical setting [104].Serendipitously, dental
implant placement surgery was also faster [102]. In craniofacial surgery, using a navigation sys-
tem makes the surgery not only faster but also safer and more accurate, minimizing surgical
injury, especially in deep anatomical areas [99,100].A logical extension to dynamic surgical
navigation is made possible with mixed reality, integrating aspects of both virtual and
augmented reality technologies, further enhancing human visualization. Virtual reality makes
images seem real, even though the environment is synthetic, created through the combination
of virtual reality equipment (e.g., Google Glasses; [Link] and a computer.
Mixed reality integrates the real environment int the virtual space, fusing the two [105]. One
demonstration of this approach is described in detail by Kubota and Yoshimoto [105] and can
be viewed at[Link] WRbj-w.4.2. Robots already in
dentistry Non-dental proliferation of robots has been astounding. They autonomously deliver
packages [106], perform a host of functions in manufacturing and research, and a pair of
robots have been shown to assemble flat-pack furniture in less time (and with no arguments)
faster than humans [107]. Elementary-and middle-school aged children build and compete
with LEGOTM-built robots [108].Robotics have been adjuncts in medicine since 1992. One
major company shipped 5770 robotic surgery systems in 2017[109]. In 2017, an estimated
877,000 robot surgical procedures were performed [109]. In addition to surgical support,
robots also serve medicine as physician assistants, provide a telepresence as well as aiding in
rehabilitation robots and medical transport, sanitation and disinfection, and prescription
dispensing systems [110].Robotics utilization in dental applications have been less prolific in
dentistry. In 2001, a remotely located but human-controlled robot removed caries, completed
a crown and bridge preparation, and performed endodontic therapy [111].Robots’ tooth
preparation skills have been tested, showing that a robot’s laminate veneer preparations and
crowns are as accurate as those of human clinicians [112–114]. However, the crown
preparation was done with lasers that required unrealistic cutting times [113,114].Wire-
bending robots for orthodontic wires were introduced round the turn of the century [115].
Recently, a mobile wire-bending machine was introduced [116]. Using intraoral scan data, this
mobile system can create a fixed orthodontic retainer wire in only four minutes. The YOMITM
robot for guiding implant surgery (described above) was approved for use in2017 [97]. In 2017,
a robot dentist in China inserted two dental implants to an accuracy of 0.2–0.3 mm in a live
patient with human supervision but with no intervention [117].4.3. A different approach to
one-visit crowns and bridges One of the advantages first described for CAD/CAM systems was
chair-side one-visit restorations. CAD/CAM-produced in-house can deliver a restoration in a
single visit but doing so with ‘traditional’ CAD/CAM systems usually requires a relatively long
appointment awaiting design and fabrication of a final restoration. In 2017, a new approach
was introduced that shortens appointment time while still delivering crowns and bridges from
the diversity of existing materials [118]. With this FIRSTFITT Mapp roach, digital impressions
and bite registration are sent to a laboratory along with shade and characterization
descriptions — before the tooth or teeth are prepared for a restoration. Laboratory-based CAD
software designs the preparation and then designs and prints three sets of 3D surgical guides
for preparing the tooth (one guide each for buccal, lingual, and occlusal surfaces). At the same
time, the definitive crown or bridge is designed and printed (usually from zirconia). Only then
are the guides, a unique burr, and the final restoration sent to the dentist who prepares the
patients tooth by sequentially placing the guides on the tooth/teeth, running the burr through
grooves in each of the three guides, and then immediately seats a finished/final restoration. In
case a clinician is skeptical about the design and/or restoration fit, the laboratory also sends a
stone model of the patient’s dentition so that he/she can practice the technique and confirm
that the intraoral preparation meets their demands and expectations. One must wonder what
influence this may have for the future. How will unanticipated intracoronal pathologies be
managed? Will preparations be completed by assistants and only confirmed as acceptable by a
dentist? 4.4. Scaffolds and tissue engineering Data acquired by cone beam computed
tomography (CBCT) and other digital imaging techniques married with 3D printing has
significantly influenced tissue engineering [119–121].Transforming craniofacial reconstruction
over the last two decades, this integration has open new options for complex craniofacial
reconstruction through personalized scaffolding constructs based on individual patient-specific
anatomical data [121,122]. Site-specific topographic and internal geometry, interconnected
pore structure as well as mesoscopic and macroscopic porosity, can all be tailored to
patient/application needs [123,124]. Scaffold properties, such as stiffness, can be tuned to site-
specific requirements [125].While already used in an array of applications, scaffold use has
recently also focused on inter-dental scaffolds. Vasculogenesis in root canals is successful, even
fabricated with a hand-held bio printing system [126]. Micro-patterns of the human dentin-
pulp complex have achieved more than 88%viability [127,128].Bio-inks, making it possible to
integrate live cells and temperature-dependent pharmaceutical agents into scaffolds, have
been demonstrated [129–131]. An enlightening summary discussing biocompatibility,
printability, and mechanical properties of extrusion-based bio-ink-printed scaffolds is given by
You et al. [132]. Zhu et al. describe advances and challenges in inkjet dispensing technology
related to drug discovery [133]. While much has been done, there is still much to learn about
printing structures that induce tissue and organ regeneration [134].It is impossible within the
constraints of this manuscript to give a complete summary of developments in this exciting
field. Already in the first half of 2019, 49 articles referenced in PubMed focused on creating
scaffolds and tissue engineering for teeth. Digital dentistry’s influence on scaffolds and tissue
engineering cannot be overlooked. Unquestionably it is a ripe field for material science.
5. Other digitally enabled applications influencing dentistry
Other digitally enabled applications influence dentistry include innovations in technology-
enabled health monitoring and care; telehealth; the confluence of forensics, epidemiology and
artificial intelligence; and evolution of and innovation in dental education. Often overlooked,
these are likely to have a profound effect on the future of dentistry and on us personally.5.1.
Technology-enabled health monitoring and care Modern devices track activity, health, fitness,
and environ-mental factors continuously, without interrupting daily life. And they are
becoming increasing more sophisticated and popular. Advances in miniaturization of flexible
electronics, electrochemical biosensors, micro fluids, and artificial algorithms [135] have
enabled the extraordinary evolution and proliferation of wearable devices. Already by 2014,
over 100,000 health apps were available for IOS and Android software [136]. Globally in 2018,
172 million devices were shipped. Of these, 53 million were smart watches 2018 [137].The
diversity in types and capabilities of devices in remarkable. Devices can extract data from
contact with epi-dermal, ocular, intracochlear and dental surfaces [135]. Many capitalize on
artificial intelligence to offer real-time micro-interventions to minimize or preclude disease. By
way of examples, consider the following. At least one wearable garment, that is washable, can
track ECG and heartbeat, stress, fatigue, QRS events, heart rate recovery, breathing rate,
ventilation, activity intensity, peak acceleration, steps, cadence, positions, and best sleep
[138]. Contact lenses monitor glucose levels, smart pills monitor medication intake behaviors
and body responses; wrist bands monitor heart rate, blood pressure, calories burned; insole
sensors measure weight bearing, 7balance and temperature [139–144]. A wearable ECG
monitor, embedded in clothing, can record over 20 million data points each day, giving a
medically accurate electrocardiograph trace and shares data directly with your doctor
[145].Smart tooth brushes monitor and report effectiveness of brushing and include games
and feedback to teach children how to brush properly [146]. Smart spoon offsets hand tremors
(interchangeable spoon, fork, and key) [147].
5.2. Telehealth
Telehealth Data from smart digital health devices can be reported directly to clinicians/health
care providers. Not surprisingly, telehealth is expanding rapidly. Telehealth empowers patient-
health care delivery, communications with both patients and for consultations with other
professionals and brings health care into underserved areas and to people with difficulty
traveling to health care facilities. Additionally, it facilitates distance learning. In a word,
telehealth dramatically expands point-of-care options and diagnosis. As with other digital
areas, innovations in sensors, computer prowess, and data acquisition are integrated into
highly instrumented devices that open new pathways for individual-health care provider
communication. Because they can transmit high quality, high-resolution data, realistic on-
demand physical examinations and interface with a physician virtually has become possible —
and popular. As early as 2013,a major health insurance company with 3.4 million members in
its system, reported 10.5 million virtual visits [144].One handheld examination kit includes an
examination camera, basal thermometer, otoscope, stethoscope, and tongue depressor. An
associated app provides a link for dialog with a health care provider. The kit and app are
commercially available for a cost of under $300 [148]. Charges for the video consultation are
usually lower than in-office visits. So, the patient doesn’t have to leave home to have an
examination and the cost of the ‘appointment’ with the physician is lower than an in-person
visit. Other mobile systems integrate communication software with real-time active input of
patient clinical data. One, a carryon suitcase size mobile system, creates the ultimate portable
practice, offering a breadth of diagnostic features and capabilities including weight and height,
stethoscope, general exam camera, EKG, spirometry, vision, retinopathy, hearing screener,
ultrasound, portable X-ray, bone dentistry, PACS (storage and access to images from multiple
modalities),ABI (for diagnosis of peripheral vascular disease), colposcopy, concussion testing,
and dental examination. Incorporated algorithms provide real-time language translation. With
this dramatic array of compact mobile technology complete examination capabilities are
brought to the patient [149].In dentistry, telehealth has been used for a host of
conditions/situations. These include remote screening, oral lesion diagnosis, management of
dental emergencies for French sailors [150], cephalometric analysis via smart phone
[151],monitoring orthodontic treatment [152], screening of potentially malignant oral
disorders [153], diagnosis and treatment planning in mixed dentition [154], screening children
in underserved areas [155], providing support for dental health clinicians in rural or isolated
locations [156], and screening for the need of health care of people in care homes and in
prison[157,158]. In 2017, the American Dental Association added tele-dentistry codes to codes
used for billing procedures [159].Clearly digital systems have had an impact. Patients and
clinicians both find advantages with telehealth. Telehealth brings health to patients rather
than requiring patients to move to health centers for care – a critically important adjunct for
those where otherwise care would not be possible. In underserved areas, it promises
possibilities for care to be delivered by an array of different health care providers who can be
meaningfully informed by experts at remote locations.
5.3. Forensics, epidemiology, and artificial intelligence
The wealth of data contained in the digital data set is a goldmine for both forensics and
epidemiology. In forensics, it is vital in assisting investigators in providing information that
helps identify victims or mining electronic patient records [162,163] can enable perpetrators in
natural and manmade disaster situations [160,161] .Tracking prevalence and distribution of
oral diseases. Properly applied artificial intelligence, especially when combined with deep
learning, can remove monotonous repetitive tasks from humans and do them quickly. As an
example, IBM’s Wat-son can read 500,000 medical research papers in 15 s and, with deep
learning, can recommend diagnoses and most promising treatment options [164]. This is
particularly valuable in tasks like interpreting radiographs and especially CBCT’s multiple image
slices, caries detection, early detection and progression of various disease states, and a host of
other questions of epidemiological interest [165].5.4. Education Digital haptic and simulation
systems have become important adjuncts in teaching dentally related skills [166]. The real-
time feedback through tactile sensation has been applied to locating carious tissue and
injection technique [167,168], teaching insight into dynamic occlusion [169], locating
cephalometric landmarks [170], tissue compliance in surgery [171], and drilling for implant
placement [172]. As schools struggle with falling numbers of instructors, haptic systems
become increasingly valuable by reducing faculty supervision demands [173]. While valuable,
learning is best optimized through a combination of instructor and virtual-reality feedback,
rather than one substituting for the other [174–176].Second Life, an online virtual world with a
social environment, can be considered as a learning supplement for preclinical teaching
methods. Using 3D models virtual models, students can more easily understand anatomical
interactions that are difficult to observe in real life and it appeals to digitally-savvy students
[177].Robot-based simulation systems programmed to simulate host of physiological
conditions are useful in teaching dental techniques as well as patient management [178]. One
particularly interesting robot is Simroid TM[179,180]. It/she looks like a petite woman in a pink
sweater. Its teeth are fitted with sensors and it cries out when a vital nerve is touched,
grimaces to show pain, and moves its/her hands and eyes to say that ‘it hurts’. This robot
simulates patient reactions and accidents during treatment, including reaction to pain,
coughing, vomiting reflex, irregular pulse, and irregular movements.
6. Digital technology can create strangebedfellows
6.1. Telehealth and Uber
Three telehealth vendors have teamed up with Uber to give hospitals and health systems a
new way to deliver health care. In March 2018, Uber introduced Uber Health, a new business
line that provides a ride-hailing platform available specifically to healthcare providers [181].
Now, Uber Health and three tele-health companies have joined to create a program whereby
care providers can arrange to have a telehealth kit delivered to a remote patient or bring the
patient to a local clinic that has telehealth capabilities [182,183]. Besides the obvious groups
that can capitalize on this arrangement, it could be extremely valuable during natural
disasters, accidents and battlefields.6.2. ‘Do-it-yourself’ orthodontics and pharmacies Driven
by digital information and computational prowess, digital photography, intraoral scanners and
additive manufacturing, ‘do-it-yourself’ orthodontics is an alternative for working adults and
those living in underserved communities [184]. In many respects, it is an extension of
telehealth. For this alternative, a patient’s intraoral scan is sent to a company that makes a
series of aligners, step-wise moving teeth to the most ideal position. (It should be noted that
the patient is also given the option of taking their own conventional impressions by themselves
with company-provided materials.) Some companies have created their own scan shops or
studios designed specifically for capturing intra-oral scans. One has established relationships
with two pharmacy companies in a host of major cities where intraoral scans can be captured
[185].
7. Digital dentistry — is it disruptive ordestructive?
Change is accelerating. The transfer of narrative to hand-written information lasted for
200,000 years. Handwritten to printing lasted 4800 years, analog to digital lasted 540years
until the World Wide Web was invented in 1989/[Link], a mere 30 years later,
transformation to artificial intelligence and advances in neural networks is underway [186].This
latest transformation is fueled, in part, by the EU-sponsored Human Brain Project’s $5.4 billion
of funding to “accelerate development and application of innovative technologies to
revolutionize our understanding of the human brain, including development of humanoid
robots equipped with biotechnical neural artificial intelligence” [186].Dentistry has changed
and will continue to change. Among some previous disruptive changes, consider the following.
Few clinicians would consider using cocaine toothache drops or alcohol for anesthesia and
now researchers are experimenting with nanobots control nerve-impulse traffic, eliminating
sensations [179]. Since its discovery in 1895 and the first dental application in 1896,
radiography exposure times have dropped from 25 min [187] to fractions of seconds,
determined by dosage calculations. Flat-plane images have been complemented by intraoral
scans, 3D CBCT, intra-oral scanning, plus, in special situations, PET, MRI, and other imaging
modalities [10]. Drills/hand pieces have morphed from flint tips found in7500 to 9000 year old
teeth [188] to bows operated by crafts-men [189] from foot-powered slow speed in 1864,
when the clock-work drill was invented to pedal-operated burr drill in1871, ultimately to air
turbine high speed water cooled drills first patented in 1949 [190,191]. Gloves for clinical
procedures were not mandatory before the mid-1980, largely in response to HIV/AIDS
epidemic, despite the fact that clinicians were well aware of disease transmission long before
that date [192].Materials and approaches to dental restorations have changed dramatically
over time as is well known to most readers of this journal. A broken tooth 6500 years ago was
‘restored’ with a simple wax cap, the oldest recorded dental filling [188].A book with
systematic description of dental diseases and their treatment existed in Roman Imperial times
between25 BC and 50 AD [193]. Missing Roman teeth were restored with gold wire supporting
a replacement human tooth with evidence that both steel and ivory were also used. There
have been remarkable improvements in material choices and techniques over time. Perhaps
the three most revolutionary modern advances are Buonocore’s 1955 introduction to the
feasibility of adhesive dentistry [194–196], Bowen’s resin-based composites [197,198], and
Branemark’s understanding of the induction and management of osseo integration
[199,200].Throughout the ages, dentistry has survived and flourished despite all these
changes. Care and longevity of the teeth and the oral-facial complex has improved. Digital
dentistry has changed how dentists think and function. It has improved the patient’s
experience. It has created a distributed workflow to capitalize on the best expertise for
different functions. Unquestionably, the impact of digital dentistry is disruptive —but in no
way is it destructive.
8. Opinions on digital dentistry’s opportunities for material scientists
Digital Dentistry’s opportunities for material scientists are extensive and far reaching. They
range from capitalizing on additive manufacturing for developing new materials, developments
to improve and simplify restoration with implant and innovations in scaffold materials and
fabrication techniques. Complementing these is the need for standardization of testing
methods.
8.1. Capitalizing on additive manufacturing
Without question, the introduction of CAD/CAM systems has greatly expanded material
choices for dentistry. Additive manufacturing has further broadened choices. Nevertheless,
there are areas that promise ever expanding opportunities.1 Unquestionably, ceramics have
become the patient’s choice. Currently, the monolithic color of ceramic blocks demands
technician-delivered esthetic artistry. In the future, additive
9manufacturing should make it easier to locally vary color for esthetics and characterization.2
Strength and fracture resistance of layered brittle materials can be improved with introducing
functional gradients [201]. Additive manufacturing offers the potential for introducing
functional gradients into restorations as part of the normal fabrication process.3 Prosthesis
design remains unchanged from conventional designs controlled by subtractive manufacturing.
Innovations in the internal geometry, possible with additive manufacturing should be
considered and tested.
8.2. Implant materials, design, and surface
Dental implants have a long history of success, though that success is often affected by
unacceptable loading conditions, insufficient bone, and disease processes. Areas for potential
investigation may include:1 Miniaturization of sensors may make if feasible to integrate
sensors into an implant that could report overload conditions or other factors that might affect
implant longevity.2 With additive manufacturing, it may be conceivable that implants should
no longer be solid but instead be more nearly like a scaffold, permitting ingrowth of tissues
into the boney supported area of the implant itself as a component of osseointegration.3 New
materials and/or surface features may be appropriate for implants, further optimizing the
human-implant inter-face.
8.3. Scaffolds
Much has been done and is understood about materials and tissue response across length
scales. New fabrication approaches might expand their applications, leveraging what we
already know to create new opportunities.1 Some fabrication technologies create designs at or
near room temperature. How might these, or new, technologies be harnessed to create and
use advanced bioinks that incorporate living cells and/or temperature dependent
pharmaceuticals into scaffolds?2 What materials and fabrication approaches could be used to
fabricate scaffolds for flexible applications (e.g. muscle repair and ‘squishy’ robots [202])?
8.4. Standards
Materials scientists continue to be actively engaged in development of standards for materials
and testing protocols for product evaluation. There is still much to be done. As an example,
between April and July 2017, 2093 publications addressing accuracy of digital technologies for
scanning facial, skeletal, and intraoral tissues were evaluated [47]. However, only 183were full
text and a mere 4 contained data sufficient for evaluation and comparisons across studies.
Clearly, much can still be done in this area.
9. Summary
Digital systems are pervasive in our personal and professional lives. In dentistry, a core digital
data set of patient records, radiographs, photographs, and intraoral scans is the platform
revolutionizing clinical activities, enriching patient-clinician and interprofessional interactions,
transforming education, and enhancing practice management. An exponential rate of
innovation has and will continue to deliver technologies we never dreamed of. As lines
between physical, digital, and biological spheres blur, collaborations of computational design,
additive manufacturing, materials science, and synthetic biology will unquestionably help
shape the future. Opportunities for evolution and innovation in material science are
exceptional. Digital innovations have unquestionably disrupted dentistry. With these
innovations, patient experience has improved. More restoration options are available
delivering longer lifetimes, and better esthetics. Fresh approaches are bringing greater
efficiency and accuracy, capitalizing on the interest, capabilities, and skills of those involved.
New ways for effective and efficient interprofessional and clinician-patient interactions have
evolved. Data can be more efficiently mined for forensic and epidemiological uses. Students
have fresh ways of learning. New, often unexpected, partnerships have formed bringing
further disruption — and novel advantages.
Is digital dentistry disruptive? Absolutely. Is it destructive? Absolutely not!
FUNDING
This work did not receive any specific grant from funding agencies in the public, commercial, or
not-for-profit sectors.
