Around the world, people use AI-powered technology every single day. AI algorithms generate everything from Google search results to predictive text when writing emails to speech-to-text messages on smartphones. Every time you’re shopping and see “Recommended for you,” that’s based on AI data analysis, comparing your shopping habits to those of thousands of other people.

When I spoke at the annual Pankey meeting in New Orleans in 2015, my artificial intelligence software was just in its embryotic stage. Fast forward five years, and it is on the forefront of a technological revolution that improves the operations, ROI, and patient experience in dental practices of all sizes.

Data is hindsight. Intelligence is foresight.

Artificial intelligence programs are trained by using millions of data points that were categorized by humans already. AI software is taught to recognize the meaning of what it is seeing and/or hearing. Then, AI software programs extrapolate results and apply the information to predict behavior, coach behavior, command machines, and more.

9 Ways to Leverage AI in Dental Practice

Hygiene at home: Smart toothbrushes can record how patients are brushing their teeth and share that data with dentists, typically via an app. That allows dentists to identify bad habits and teach patients how to improve their at-home hygiene routine. Some apps even remind patients when it’s time to schedule their next dental appointment.

Voice-activated commands: In healthcare, medical and dental providers are already using voice-activated technology to dictate their notes into patient electronic medical records (EMR) and to access radiographs and other images hands-free. They are also using voice commands to research symptoms, diagnostics, and treatment options. This year will see an explosion of voice-activated commands in the workplace. Gartner, Inc, a world-renowned research and advisory company, predicts 25% of digital workers will use virtual employee assistants (VEAs) daily by the end of 2021. It also predicts that by 2023, 25% of employee interactions with applications will be via voice, up from just 3% in 2019.

Pathology identification: Computer vision AI analyzes radiographs in real time to detect pathologies and standardize quality of care. It provides confidence in the dentists’ diagnostics, and ensures problems are not missed. Companies like Pearl, Videa, and Overjet are successfully implementing computer vision AI in thousands of dental practices and improving diagnosis, case acceptance and ultimately patient outcomes.

Treatment planning: AI computing models are based on the treatment plans and outcomes of hundreds of thousands of patient records. Dentists can leverage AI to analyze different treatment possibilities and determine the potential for success, the length of the case, the materials that would be used, costs, and other considerations.

Treatment acceptance: Augmented reality isn’t just for kids’ games. Dentists use AI-powered augmented reality to generate smile designs in real time. When patients can see how the dental work will improve their appearance and restore function, they are more likely to start treatment.

Data analytics: At its most basic functionality, AI is big data computation. Its advanced algorithms predict future outcomes based on data patterns. Some dental support organizations around the country are already using AI to crunch numbers for predictive analysis designed to increase case acceptance, improve show rates, and optimize schedules.

Insurance reimbursement: For decades, insurance claims have been manually reviewed by dental professionals employed by the insurance carrier. AI can review claims, radiographs, and supporting documentation in seconds, generating approvals or identifying fraudulent claims much more quickly.

Elevated patient care: Technology has already revolutionized electronic health records. In this decade, AI will make it possible to closely tie oral health conditions to overall systemic health which will lead to better communication between providers and breakthroughs in both disease prevention and treatment.

Patient phone calls: Companies like Patient Prism leverage AI’s natural language processing algorithms and machine learning to quickly identify why patients called, the services they requested, the associated revenue, and whether the call ended in a booked appointment. Dentists use the data for everything from front office training to winning back unscheduled callers to determining whether their marketing efforts are driving the right kinds of calls.

Groups like the Artificial Intelligence Dental Council, a non-profit organization established by Pearl, are leading the way on the research and future applications. From helping patients at home to making it easier to book appointments to ensuring accuracy in diagnosis and treatment planning, AI is already revolutionizing dentistry. The future has arrived.

When working with participants at The Pankey Institute, I help them analyze dental cases to assess the risk for joint and muscle problems. I often hear, “The patient is not reporting any pain.” Yet, the dental records indicate the patient is at high risk of experiencing pain.

I have discovered a question to ask my patients that reveals their personal pain tolerance. “When you have a headache or muscle pain, at what level of pain do you take an Advil?” Some patients say at level 1 or 2. Others say not until it is a 12. Patients are all up and down the scale.

This one question leads to the patient’s self-discovery about how they perceive pain and potentially tolerate abnormal pain when they are “diseased.” Further conversation helps the patient understand symptoms they have been dismissing indicate abnormalities that can be “treated” for a healthier, longer-lasting dentition and more comfortable life.

And this brings me back to how we diagnose and plan treatment in general. Sometimes the questions we ask our dental patients aren’t structured to get us the information we are hoping for. If we gather inaccurate impressions from their responses to our questions, we go down the wrong path clinically. Asking more powerful, well-crafted questions allows us to better know the patient and get more complete information to better understand their situation.

I believe that some wear is normal. I base this on the fact that I have very few if any patients who are in their seventies or eighties and still have mamelons on their incisors. Wear is a concern when the amount of tooth structure being lost is out pacing the patient’s age.

In Part 1 of this series, I wrote about determining when wear leaves the physiologic category and becomes something we need to discuss with patients. Both attrition and erosion can cause severe tooth wear, but they pose different long-term risks. Once we have a sense of the cause of tooth wear, we can partner with the patient to treat the damage and manage the progression.

These are the guidelines for discerning attrition from erosion.

Attrition is the loss of tooth structure caused when the patient rubs two tooth surfaces together. You will observe:

· Matching facets on upper and lower teeth

· Facets on tooth surfaces that occlude

· Enamel and dentin worn evenly

Erosion is caused by the presence of acid from issues like GERD and eating disorders. You will observe:

· Facets that may or may not match on upper and lower teeth

· Facets on tooth surfaces that are not in occlusion

· Dentin cupped out and wearing faster than enamel

· Tooth structure wearing around restorations that remain unchanged

Note that attrition can be seen in addition to erosion, often giving us a false sense of how much the patient truly parafunctions, as the etched tooth structure wears away more easily.

When we identify patients, whose dental esthetics has been negatively impacted by altered passive eruption, our treatment plans are apt to include altering the gingival esthetics. One of the things we are tasked with is determining where we want the tissue to be.

We start by determining if the incisal edge is correctly positioned in the face.

For example, by looking at a lips at rest photograph and a full face image for my patient with altered passive eruption, we can see that the patient’s incisal edges are correctly positioned. If they were not properly positioned, we would next plan the position for the incisal edges.

Tooth proportion becomes the next building block in the planning puzzle. We know that beautiful anterior teeth are usually between 70-80% width to length ratio. This variability allows us to accommodate other clinical considerations, as well as patient preference. As a starting point, I begin with 75% and then look at the other parameters.

If the patient has excessive gingival display, and one of the hoped for outcomes is to minimize the amount of gingiva, we can alter the drawing to increase the length and then evaluate the esthetic result.  On the other hand, if there is excessive sulcus depth, we can place the proposed gingival margin within the confines of the sulcus and assess the esthetic result.

Patient Involvement

I create template drawings, like the one below, in Keynote on my Mac computer, but drawings also can be done in PowerPoint. I then sit down with my patient, insert a retracted teeth apart patient photo behind the drawing, and together we move the lines until the patient is happy with where the pink will be.

Once we have the final proposal, the next step is to determine the possible treatment options to gain the intended result. The information can easily be transferred to a wax-up or used to create a snap on trial smile.

How to Create and Use Templates

In Keynote or PowerPoint, take a retracted teeth apart photo of a beautiful, near perfect smile. Put it into the presentation software. Blow the image up to 200%. Using the free form drawing tool, trace the outline of the upper six anteriors. Take the photo out and save the presentation as a named template.key or template.ppt file.

When you want to do proposal drawings with your patient, open up the template, insert the patient’s photo and save the file with the patient’s name. You can copy and paste the tooth outlines onto any of the patient’s photos to propose gingival changes. If you pre-draw and save outline templates for various tooth sizes (ratios), you can quickly show options to your patient.

Aesthetic Zone ratios is one of many ways to evaluate the appearance of a patients smile, and also to plan for changes that will improve overall aesthetics.

In the last article on using aesthetic zone ratios we looked at comparing the width to the height. This ratio allows us to gather data and diagnose issues like vertical maxillary excess and hypermobile lip that cause this ratio to be larger than normal.

Anterior Segment Ratio

The next of the four ratios compares the width of the total esthetic zone, all of the teeth visible between the commissures at a full smile, and the width of just the anterior segment, between the distal of the canines. The first thing to do is measure the two distances. This can be done in pixels by inserting a line over a full smile photo, or measured with a mm ruler on a printed photograph. Make sure your line is placed at the inside of the soft tissue near the commissures. The relationship to real width is irrelevant as we are going to use a ratio. We then divide the width of the anterior segment by the width of the esthetic zone and multiply by 100.

Arch Width Ratio= (Anterior Segment Width/ Esthetic Zone width) x 100

Smiles that are rated as attractive have an anterior segment width ratio between 59-75%, and the average ratio is 66%. The percentages do not have a gender or age bias which makes relying on these numbers easy. If the ration is too small or too large I start to wonder about arch space issues. Often with patients with a large midline diastema you will see this ratio be larger than 75%. In these cases or cases with inadequate space I want to make sure we use wax-ups and mock-ups to ascertain that we can meet the patients aesthetic demands without the addition of ortho to the treatment plan.

There are many different ways to assess and diagnose the aesthetics of a smile. I love learning a different approach, not so I can change to it, but so I can incorporate it into what I am already doing.

I had the pleasure of attending a full day lecture by Dr. Corky Willhite on transitional Bonding. Corky is one of the dentists I respect the most when it comes to composite education, and I had not heard him teach for many years so I was really looking forward to it. With all of the great new tricks I learned about composite, what I came away with that has me most excited is the four Esthetic Zone Ratios, to analyze and improve the attractiveness of a smile.

What Are Aesthetic Zone Ratios?

Esthetic Zone Ratios is an approach to smile design, and can be used in conjunction with or as a replacement for other smile design systems. There are four aesthetic zone ratios:

• Anterior Aesthetic Zone Ratio
• Tooth Proportion Ratio
• Anterior Segment Ratio
• Central Dominance Ratio

Aesthetic Zone Ratio

The first of the four ratios compares the width and height of the esthetic zone at a full smile. The first thing you will need is a full smile photograph of the patient. I typically ask the patient to say “E” to capture this photo so I do not get their posed smile with less display. I utilize presentation software to do the analysis since the program will do the math for me. I insert the full smile photograph into a slide. I then insert two lines one from for the width from inside the upper to inside the lower lip. I then do the same thing for width taking my line from the commissures, just inside the tissue of the cheek or face. You can then get the pixels length of the two lines by placing your cursor over the end of the line and holding.

Now you are going to divide the two numbers into each other, height divided by width, then take that result times 100 and you now have a percentage. The ideal ratio is between 15-30%. If this ratio is great then 30% we can then focus on a diagnostic cause of the smile being too tall or high. This might be things like Vertical Maxillary Excess or a short upper lip. The ratio triggers me to go back and look through other photos and evaluate the face and sift tissue for diagnostic challenges. If the number is smaller then 15% we may have a long upper lip, reduced lip mobility or a short lower face.

Facial and Soft Tissue anomalies are rarely treated when we fix the teeth, but can have a significant impact on the aesthetic outcomes, and when undiagnosed can often negatively impact our dental treatment plan.

Are you routinely taking diagnostic photos with patients?

In my last blog, I discussed the possible scenarios that could occur when your patient answers their phone during an appointment. Now, I’ll explore how you can leverage smartphones to your advantage in your dental practice.

Leveraging Smartphones in the Dental Practice

Which scenario would you hope might happen with you the most? Are these all valuable experiences? Do you KNOW YOUR PATIENT more by observing each behavior? Do you KNOW YOURSELF more from your level of engagement and influence on the outcome? How will you modify your future interactions for each patient from what you have learned?

Let’s face it, for the past couple of decades we’ve had it easy. If we chose, a whole wall could be filled with charts of Baby Boomer patients. Boomers are everywhere in great numbers, most have comprehensive needs, most have the means to care for themselves, most have a high level of trust. It was an ideal patient population and still is.

Now we have Millennials. Frankly, they are initially a tough personality for more seasoned practitioners to relate with (we look at them like spoiled kids). The stark reality is that they outnumber Boomers and have plenty of dental needs. They are the future of our workload.

To relate with Millennials, they need information fast. They need to see to believe and establish trust. Fortunately, they have a camera in their pocket. Sure, I still take my full photo series and we keep the intra-oral cameras in our rooms, but when I see the slightest glimmer of doubt in a Millennial, I ask if they can open the camera on their phone. Then I pull out a photo mirror.

It’s almost as if saving the image in their device’s storage is connecting to their memory bank. They look at it several times. They text the picture to friends and post on social media. They seek validation. From cracked teeth to gingival needs to caries – for my millennials, seeing is believing. (Now if I can keep them off social media while I’m prepping their teeth.)

Here are two photos of a tooth that a skeptical patient refused to crown because there were no symptoms. The “just fill it Doc” attitude changed with two simple snaps on their phone using a mouth mirror.

To be continued …

Approaching implant reconstruction as an all or nothing situation ignores the reality of future patient needs. Often it is too expensive for patients, who will not be able to proceed fully with treatment. They then receive only part of the complete treatment plan.

For example, with an edentulous arch the difference between a lower denture with two implants and locators as opposed to five implants with a fixed restoration is significant.  Alternately, it’s common for patients with two implants and a lower denture with locators to be dissatisfied with their function and esthetics. They may wish to move to a fixed restoration if they can now afford it. But does the clinical situation make this possible?

Implant Treatment Planning for the Future

It’s a good idea to create a treatment plan for a patient that doesn’t eliminate their ability to select different treatment in the future that could lead to improved esthetics, health or function. Certain planning decisions must be applied when placing implants to ensure necessary spacing and vertical room for a fixed restoration.

Ideally, the plan would include fixe fixtures between the mental foramina for a fixed restoration. If the patient currently wants a removable with two implants, the ideal placement can be planned for five. The 2 and 4 spots can then be used for placement of fixtures with locators.

This gives enough room for three potential implants later on that are spaced correctly. Though the placement choice can be based on a clinician’s preference for where locators would be, the 1 and 5 locations allow for ideal placement of five future fixtures. Still, many patients will have two fixtures between the mental foramina that negatively impact proper spacing for a fixed restoration. On top of this, the lower ridge position is another important factor to consider. It must be managed to account for vertical space.