TECHNOLOGY

COVER STORY

DIGITAL DENTISTRY IN

ABSTRACT
Background and Overview.

THE COMPUTER AGE

Computers are becoming an inte-
gral part of the practice of den-
tistry. Smaller, smarter and more
ergonomic computing devices will
TITUS K.L. SCHLEYER, D.M.D., PH.D. support an increasing proportion
of dental practice activities. Tech-

C
nology will make practice man-
agement more efficient, mainly
omputer technology has brought about so many changes in the by reducing transactional over-
head. Educational software and
last 50 years that many people look at the future with a mix- intelligent assistants will increas-
ture of vague unease and excited anticipation. Considering the ingly support the needs for deci-
sion making in clinical practice.
extent to which computer technology has changed our lives Research will benefit from auto-
mated tools for data acquisition,
within the last generation, it is reasonable to ask ourselves, management and analysis.
“What else will the future bring?” Even the most erudite and well- Conclusions. Dentistry must
actively shape the application of
researched predictions have the tendency to become next year’s humorous technology. It can do this by
anecdotes of computing history. In 1943, Thomas Watson Jr., then developing a cadre of experts in
dental informatics, relying on
chairman of International Business Machines Corp., or IBM, probably for- sound research principles, effec-
tively disseminating best prac-
mulated one of the most poignant ones when he declared that “I think tices and developing strategic
there is a world market for about five computers.” By the end of 1998, 364 objectives for the implementation
of technology.
million personal computers were installed worldwide.1 Clinical Implications. Computer
technology is an essential ingre-
dient for state-of-the-art patient
A second issue is that it is discussion of general computing care. Dentists must stay current
becoming difficult to write about trends, see Howard10 and Miller with this rapidly developing field
any topic with any degree of and Kirchner11). I then extrapolate to make appropriate choices in
authority.2 One of the root causes some of these trends’ effects on their use of technology.
of this problem is that knowledge dentistry and detail others that
is being generated and recorded at are well underway. I conclude the
an exponential rate.3 Much of this article by suggesting a few steps
information is more accessible that the profession could take to
than in the past. This phe- help shape the development and
nomenon is producing new application of technology. Thus,
approaches to the creation, dis- through this article, I hope to
semination and retrieval of scien- stimulate a vigorous discussion of
tific knowledge,4-9 but it also the profession’s future in the dig-
makes the job of the author ital age. Interested readers are
harder. invited to continue this discussion
Thus, this article is like a on ADA ONLINE’s discussion
searchlight sweeping through the forum at “http://www.ada.org”.
night. I illuminate some—but, by
TRENDS IN COMPUTING
far, not all—trends in computing
technology (for a more detailed Hardware. Few people foresaw

JADA, Vol. 130, December 1999 1713

Copyright ©1998-2001 American Dental Association. All rights reserved.
 COVER STORY

DENTISTRY that the conceptually simple integrated
circuit one day would play a crucial role in
2000 many areas of human life. Miniaturization
of circuits to date has followed
Moore’s Law, which was
During the 1980s,
derived by Gordon Moore in
office workers were 1965 when he was research
happy just to have and development director at
Fairchild Semiconductor.12
personal computers Moore stated that chip den-
on their desks. sity—the number of transis-
tors per square inch—seemed
Today, the network
to double at regular intervals.
connection is the Thus, 1975’s 8080 processor
essential accessory. with about 10,000 transistors
has evolved into today’s Pen-
tium III with approximately
7.5 million transistors. Ex-
Te c h n o l o g y
information access in more places. In fact,
Dick Tracy’s computerized wristwatch
now is a reality. It is called WatchPad and
is developed by IBM.14 In the future, we
may use such miniature computing
devices either directly or embedded in
other appliances.
Networking. “The network is the com-
puter.” Sun Microsystems’ advertising
slogan illustrates how our paradigm of
computing has been turned on its head.
During the 1980s, office workers were
happy just to have personal computers on
their desks. Today, the network connec-
tion is the essential accessory. In addition,
few people foresaw the transformation of
an obscure research project into today’s
Internet,15 which is a global network of sev-

perts expect that there will be 1 billion eral hundred million computers. Figure 2
transistors on a chip by the year 2010.11 shows a visualization of data traffic over
Figure 1 shows a 6-millimeter-long wood the Internet in the United States during
ant carrying an integrated circuit that is 1 September 1991. Traffic ranges from zero
mm2. The microchip’s smallest features bytes for local connections to up to 100
are 300 nanometer—300 billionth of a gigabytes for the transcontinental back-
meter—wide. bones—high-capacity communication lines
Miniaturization and integration, how- that connect regions and countries—per
ever, have not been limited to computer month. Today, data traffic and the number
chips. Sensors, storage devices and periph- of access points have multiplied by several
erals such as monitors have become orders of magnitude. The Internet already
smaller as a result of their components has reshaped our society, from economics
shrinking. For instance, the average hard and business to education and social
drive of a desktop com-
puter currently stores
approximately 4 giga-
bytes (1 gigabyte is
approximately 1 billion
bytes or characters) of
information. Ten years
from now, the average
capacity will be closer
to 200 gigabytes.11
Developments such as
these have made pos-
sible the existence of
personal digital assis-
tants, high-resolution
flat-panel screens, sub-
notebooks and wear-
able computers.13
Smaller, more
capable computing
Figure 1. Scanning electron micrograph of a wood ant (Formica
devices translate into fusca) with an integrated circuit that is 1 square millimeter, magnifi-
increasingly versatile cation ×10 (Andrew Syred, Science Source/Photo Researchers).

1714 JADA, Vol. 130, December 1999

Copyright ©1998-2001 American Dental Association. All rights reserved.
 COVER STORY

Simply download it to your DENTISTRY

hand-held book21 from your
personal elec- 2000
tronic literature
library through In the future,
your cellular interacting with
phone. On a busi-
ness trip during computer networks
your son’s will be as common
birthday celebra-
as using the tele-
tion? Simply join
the party through phone is today, but
your hotel’s in- more powerful and
room videoconfer-
encing system. natural.
Future networks
will assume an

Te c h n o l o g y
intelligence of their own. Such
“smart” networks will dynami-
Figure 2. Visualization of U.S. data traffic over the Internet
in September 1991. The colors represent traffic volume cally and independently react
ranging from zero gigabytes (purple) to 100 gigabytes to specific situations, much as
(white) (NCSA, University of Illinois; Science Source/Photo
Researchers).
an experienced taxi driver
selects an alternative, faster
lives.16-18 Future changes will make today route in response to a sudden traffic jam
seem like a period of relative stability. during a routine trip. On demand, such
For the foreseeable future, networking networks will route information to us or
will advance through three trends: higher connect us with other people, as well as
bandwidth, more access points, and sometimes anticipate our needs.
increasingly versatile and dynamic net- Software. In the near future, software
works. Bandwidth is the amount of data will evolve in two major directions. Soft-
that can be transmitted in a fixed amount ware will become smarter, and we will
of time19 and is similar to a pipe’s ability to interact with it differently. These changes
carry water. Instead of viewing still shots will be gradual, but they are well under
or a miniature video of an ant colony,20 in way. More and more software incorporates
the future, we will be watching the ants the ability to “reason” or “think” about
live on the screen. An increase in the specific problems. Many users of Microsoft
number of access points will result in Word may wonder at its increasing
more computing devices connected to a propensity to do things such as changing
network and, by extension, to the capitalization and suggesting document
Internet. Some examples of information formats. This functionality uses mathe-
access anywhere, anytime are smart matical probabilities to predict outcomes
refrigerators that reorder groceries auto- and is a method commonly used in artifi-
matically over the Internet, Web-enabled cial intelligence applications. Researchers
cellular phones and hand-held computers, are developing intelligent assistants that
and automotive navigation systems that learn from a user just as a human appren-
point the way to the nearest fast-food tice would.22 Such assistants then can
outlet. make routine decisions and leave more
Such networks will be increasingly ver- complex problems to their human counter-
satile and dynamic. In the future, inter- parts. Our interaction with software and,
acting with computer networks will be as thus, computers will change to methods
common as using the telephone is today, that are more natural for us. The develop-
but more powerful and natural. Forgot ment of the keyboard and the mouse pri-
your favorite book on a weekend trip? marily was driven by the need for char-

JADA, Vol. 130, December 1999 1715

Copyright ©1998-2001 American Dental Association. All rights reserved.
 COVER STORY
DENTISTRY acter- and pointer-based input. During
recent years, speech input has quietly
2000 matured into a technology being accepted
by mainstream computer
users.23 In combination with
Dental software
domain-specific speech pro-
companies are cessing applications,24 speech
working on recognition can effectively sup-
port application areas such as
exchanging patient dentistry. Speech, however,
information over the will not remain the only way of
interacting with computers.
Internet, potentially
Face and gesture recognition,25
revolutionizing the biometrics26 and virtual envi-
27
way in which ronments will make inter-
acting with computers much
practitioners share more natural and convenient
patient data. than it is now.
EFFECTS ON THE
PROFESSION
Te c h n o l o g y
I now turn to look at how current and
future innovations affect clinical practice,
practice management, education and
research. My discussion is limited to a few
considerations that can serve as starting
points for future in-depth discussions and
analyses.
Clinical practice. Many innovations
articulated in Preston’s28 vision of com-
puters in dental practice are becoming
reality. The paperless patient record has
come to life through smaller, more pow-
erful computing devices and sophisticated
software. The fact that it is not in
widespread use attests to the multidimen-
sionality and complexity of dental infor-
mation and environmental factors rather
than technical limitations. Falling prices
for mass electronic storage have made it
possible to store an entire year’s worth of a
dental practice’s radiographs on an afford-
able hard disk. New sensors, laser scan-
ners and intraoral cameras allow us to
convert all artifacts associated with tradi-
tional patient care documentation into dig-
ital form.
Where and how we store patient infor-
mation will become significantly more flex-
ible in the future. Dental software compa-
nies are beginning to market Web-based
patient records,29 which store patient data
on a central Web server instead of on a
1716 JADA, Vol. 130, December 1999
Copyright ©1998-2001 American Dental Association. All rights reserved.
computer in the dental office. Dental soft-
ware companies also are working on
exchanging patient information over the
Internet, potentially revolutionizing the
way in which practitioners share patient
data. These changes parallel the trend to
an increasingly networked health care
system.30,31
The Internet’s power comes from the
fact that it connects people. By the year
2000, approximately 130 million people
will be using the Internet in the United
States. In 1997—the latest year for which
figures are available—about 25 percent of
dentists had Internet access in their
offices.32 Physically, dentists are in a very
“unconnected” profession. Fully 67 percent
of all dentists are in solo practices,33 and
many lack easy access to colleagues and
resources such as libraries. Being able to
communicate with a colleague at a
moment’s notice is invaluable. Many den-
tists already are using the Internet to
access diagnostic and therapeutic informa-
tion, discuss clinical cases and keep up
with new developments.34-36 The Internet
provides copious resources that can be
used in clinical dentistry18,37,38; however,
the quality of resources must be examined
carefully before they are used.39-44
Devices and software that are directly
used in the clinical care process—such as
digital image sensors, mechanical and bio-
chemical sensors and probes, simulators,
and computer-aided design or computer-
aided manufacturing equipment—will
continue to develop. Their usefulness,
however, will rise to a greater degree if
they are imbedded in an overall system
rather than used alone.
Practice management. Practice man-
agement is the functional area in den-
tistry most highly penetrated by computer
technology. As of 1997, 79.5 percent of all
dental practices were computerized.32
More than 90 percent of those practices
use computers for practice management.
Practice management encompasses many
different functions, such as billing and
insurance processing, patient communica-
tion and scheduling, inventory and supply
management, and personnel and financial
management.

Economic constraints may force dental
offices to become more automated. In the
early 1990s, double-digit inflation of
health care expenditures prompted signifi-
cant changes in the health care system
aimed at reducing costs. As increasing
automation in other sectors demonstrates
economic benefits, the health care system
in general, and dentistry in particular,
must consider new ways to become more
efficient. Computer technology can lower
practice overhead by automating routine
tasks such as sending appointment
reminders, reordering supplies and moni-
toring practice finances. Automation may
prove to reduce costs, as well as to
improve clinical outcomes through system-
atic, comprehensive and periodical anal-
ysis of health outcomes, for example.
Education. Computers and the
Internet are revolutionizing the process of
education at all levels.45-47 Not only are
computers becoming a key tool in the edu-
cational process, they also make education
available in places and at times in which
it was previously inaccessible. Students in
the health professions now dissect
cadavers on the computer screen,48 pre-
pare teeth with real-time feedback from a
computer49 and practice surgical proce-
dures in simulators.50 Distance education
makes single courses and whole degree
Figure 3. A biochemist using a virtual reality system to
investigate molecular interactions (Geoff Tompkinson,
Science Source/Photo Researchers).
Copyright ©1998-2001 American Dental Association. All rights reserved.
COVER STORY
programs available anywhere and at any- DENTISTRY
time.
Dental education and con- 2000
tinuing education will be
reshaped by three trends: Computer technology
increasingly realistic learning can lower practice
aids, intelligent tutoring sys-
tems and the merging of overhead by
learning systems with clinical automating routine
decision support. For instance,
tasks such as
in a virtual reality environ-
27
ment, the human heart can sending appointment
be observed not only statically reminders,
but also in function. Such
realistic learning systems can reordering supplies
make content come alive and and monitoring
improve students’ under-
standing and comprehension. practice finances.
Intelligent tutoring systems
will recreate a very effective
Te c h n o l o g y
model of education that, for the most part,
has lain dormant for several centuries:
that of the personal tutor. Such systems
work like the personal tutor who gets to
know the strengths and weaknesses of a
particular student very well and remedies
them personally. These systems also con-
stantly assess the knowledge and perfor-
mance of their students, select the appro-
priate learning materials to help them
improve, and even adapt to the students’
learning styles.
Over time, the line between
education and practice will
become much less distinct.
Researchers are beginning to
integrate continuing education
into clinicians’ daily work
flow.51,52 Both education and
practice use the same raw
materials: knowledge and expe-
rience. The challenge for infor-
maticians is to devise systems
that can effortlessly change
shape in an instant—from
explaining the details of a ther-
apeutic procedure one moment
to helping formulate a differen-
tial diagnosis for a patient the
next.
Research. Computers have
been an essential tool in
research for a long time. Figure
JADA, Vol. 130, December 1999 1717
 COVER STORY
DENTISTRY 3 shows an example of applied virtual-
2000 reality modeling that allows researchers
to test a variety of theories by manipu-
lating a protein sequence on a
Dental informatics is computer. We now are entering
an era in which computer pro-
an exciting new field grams will perform much of the
that seeks to use discovery for us. Dental mate-
rials research already has capi-
information talized on the capability to test
technology to materials on the computer vs.
by in vitro or in vivo methods.53
improve processes
Swanson and Smalheiser54
and outcomes in described a system that facili-
dental practice, tates the discovery of previ-
ously unknown cross-specialty
education and information of scientific
research. interest that allows
researchers to discover new
correlations between variables
with the help of a computer program.
Te c h n o l o g y
Computers also increasingly are used to
acquire and analyze research data
directly. This creates new alternatives by
making details normally hidden to the
human eye or mind accessible.55 For
instance, the human eye can distinguish
between approximately 40 shades of gray
on a radiograph. Digital image analysis
programs, on the other hand, can process
thousands of shades of gray.
Research results are of little value
without effective dissemination. Online
journals—such as the British Medical
Journal at “http://www.bmj.com”—address
the method, timeliness and scope of dis-
semination. For instance, readers can reg-
ister their topics of interest with the
British Medical Journal and receive an
Figure 4. Dental informatics is a discipline integrating dentistry, cognitive sciences, computer
science and telecommunications to support practice, research and education (Roger Kenney,
D.M.D.).
1718 JADA, Vol. 130, December 1999
Copyright ©1998-2001 American Dental Association. All rights reserved.
e-mail message when a related article is
published.
ACHIEVING THE FUTURE
What future information technology will
bring to our profession depends not so
much on how technology evolves, but
rather on how we apply it. The profession
must turn from being an observer into
being a creator of phenomena induced by
new technologies. Doing so is a matter of
survival, not convenience. History offers
few lessons, but some measures may help
achieve a successful union of dentistry and
computer technology.
Develop a cadre of people with
formal training in dental informatics.
Dental informatics is an exciting new field
that seeks to use information technology
to improve processes and outcomes in
dental practice, education and research.
Like a prism in reverse, dental informatics
unites several fields, including dentistry,
cognitive sciences (how humans obtain,
store and retrieve information), computer
science (how computers and programs
should be designed) and telecommunica-
tion (how information should be trans-
mitted) to create novel solutions to prob-
lems in dentistry (Figure 4).
To make dental informatics into a core
competency and a broad enabling disci-
pline in support of the dental profession,
we must invest in qualified people.56 In
1997, the National Institute of Dental and
Craniofacial Research recognized this
need by establishing the first fellowships
in dental informatics.
Build a culture of scientific investi-

gation based on sound research principles.
While it is possible to conceive of an ingenious
software application on the spur of the moment or
through undirected experimentation, it is the
exception rather than the rule. As in many other
fields, dental informatics must advance through
systematic research that consistently increases
the theoretical and practical foundation of dental
computing applications.57 To succeed, dental
informatics must base itself on a collection of
research principles similar to those formulated
for medical informatics.58-60
Disseminate research findings and best
practices effectively. Knowledge of what works
and what does not work in dental informatics
must be shared. As recently as 1995, 31 percent of
all software projects in the United States were
canceled before completion, and 53 percent of all
software projects overran their cost estimates by
189 percent.61 Even in a dental practice, the
hidden costs of unsuccessful or only partially suc-
cessful computing projects can be tremendous.
Best practices and research findings must be dis-
seminated widely and effectively to allow all prac-
titioners to benefit. With the recent establish-
ment of an Informatics and Technology section,
JADA has provided an avenue to do so.
Develop a strategy and goals to imple-
ment computer technology in dentistry.
Computer technology currently sets few limits on
what we can do. To derive maximum benefit from
this latitude, however, we need a comprehensive
strategy. While this does not mean we should
adopt a paradigm of centralized control,62 many
worthwhile objectives cannot be achieved without
a significant amount of coordination and stan-
dardization.28 The establishment of the ADA’s
Standards Committee for Dental Informatics pro-
vides dentistry with the opportunity to set stan-
dards that will shape the implementation of
computing technologies in dentistry for decades
to come. Any proposed standards, however,
must be rigorously evaluated before they are
implemented.
CONCLUSION
The recommendations I give in this article are
only a few that may help us realize the opportuni-
ties that information technology sets out before
us. Despite the best-laid plans, however, com-
puting reality has a curious way of surprising us.
For example, patients now are beginning to store
their own health information on Web servers.63
Copyright ©1998-2001 American Dental Association. All rights reserved.
COVER STORY
One reason cited for this trend is
that the health care industry has
been slow to adopt computers,
prompting patients to take mat-
ters in their own hands. Patients
appreciate that they can make
Dr. Schleyer is an
their health information avail- associate professor
able to any health care provider and chairman,
with a Web-enabled computer. Department of
Dental Informatics,
Another caveat is that inces- Temple University
sant and relentless pace of inno- School of Dentistry,
3223 N. Broad St.,
vation should not force us to Philadelphia, Pa.
accept new technologies just for 19140-5096.
their own sake. Quite a few com- Address reprint
requests to Dr.
puting technologies have turned Schleyer.
out to be a solution in search of a
problem. Critical appraisal and analysis must
precede adoption, even if our understanding of
potential effects remains limited.
Regarding information technology, one thing is
certain: The new millennium will bring plenty of
surprises. ■
The author would like to thank Dan Boston, Roger Kenney and
Hikmet Umar for their comments during the preparation of this paper.
Readers who are interested in discussing the future of computers in
dentistry further may join the author in the ADA ONLINE discussion
forum at “http://www.ada.org” to continue the discussion of how infor-
mation technology will affect the dental profession. The discussion
thread is titled “Digital dentistry” and will begin when JADA readers
receive this issue.
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