If you talk to a number of older dentists, they will speak about the 1960’s and 1970’s as the “Golden Age of Dentistry”. It was a time of great discovery, formation of new specialties, new materials and techniques, and enough demand to keep everyone busy. If this truly was the ”Golden Age”, then dentistry has been experiencing a Renaissance since the mid 1990s. The phenomenon that has been driving this era is technology. The advent of dental practice management software, intra-oral cameras, digital radiography, and digital imaging has completely changed the look and feel of the dental office. When it is used correctly, technology can allow any office to be more productive, increase case acceptance, reduce tedious paperwork, and attract more patients to the practice.

One of the main problems in dentistry, however, is the lack of an accepted standard for these technology systems. A data file from one practice management program is not compatible with another program. Manufacturers of digital radiography systems and intraoral cameras require proprietary software and hardware to run correctly, and many require special “bridges” to integrate with practice management systems. Further complicating the situation is that a few large companies have been purchasing and consolidating a number of these systems, making it difficult for the practitioner to know exactly who will be providing service and support, and whether their systems will even be supported at all!

The purpose of this article is to assist the new practitioner and senior dental student in making the proper choices when it comes to adding technology to the dental practice. We will explore the questions that need to be asked and decisions that need to be made when making these investments, and will hopefully steer dentists clear of the numerous pitfalls that await you.

Which Technologies to Purchase

For many dentists, this decision will be the most difficult of all. You can’t open a dental journal today without seeing large ads for intraoral cameras, digital radiography systems, digital imaging, image manipulation software, patient education systems and a host of others. One of the advantages that the new practitioner has it that most have been exposed to these systems during their dental training. They are aware of what the systems can do .For the dentist who hasn’t yet decided which systems are right for them, the following guidlelines may be of some assistance:

1. You MUST have a plan of how this technology will help you. Every office wants to appear to be on the “cutting edge”, but an intraoral camera that spends more time as a coat hanger is not a good investment! For most dentists, they need to understand how these technologies will directly affect the bottom line. Intraoral cameras, for example, allow the patient to see things that previously were only visible by the dentist. With this visual confirmation, the patient participates in the diagnosis and will be more likely to accept treatment recommendations. So, the doctor who purchases one of these systems to increase case acceptance will most likely benefit the most from it; the doctor who buys a system with no idea how to utilize it will end up making a large mistake.
2. The dentist must also evaluate their practice style to see if these technologies will adapt to that style. For example, a dentist who is uncomfortable with long discussions with patients will not benefit from a device that encourages patient dialogue. If the dentist is uneasy with computers and technology in general, then these systems may not be right for that person. A perfect illustration of this would be a patient education system in the operatory, such as Caesy. These systems are great for explaining to patients more details about the procedures that are being recommended for them. However, they are not there to sell the procedure. Some dentists fail to realize that they are not selling a procedure, but rather they are selling themselves as the best person to do that procedure. Therefore, patient education systems should not be used as a crutch.While they can all be used as standalone systems, they will have the most benefit when they are networked with all the computers in the office.
3. If you are a specialist or plan on limiting the scope of your practice, choose the system that will best help you with that goal. An endodontist will benefit most from a digital x-ray unit; a cosmetic dentist will find great help with an extraoral camera and digital imaging system, etc.
4. Try to get hands-on experience and testimonials from as many sources as you can. Most if not all sales representatives will come to your office to demonstrate their systems, but you should take their sales pitch with a grain of salt. Go online to find other users of the systems. Are they happy with their choice? Would they buy it again? How is the service and support? Ask as many questions as you can.
5. Try to find some objective evaluations of these products. Dr. Gordon Christensen’s group, Clinical Research Associates (www.cranews.com), reviews these systems on a regular basis, and will often evaluate customer satisfaction with the different systems.

Financial Considerations

For the dentist who has just graduated with a mountain of debt, there are few sticker shocks worse than pricing these systems. The dentist who goes to a large dental meeting to find a good deal is in for a big surprise! The range of prices can be quite considerable, but here are examples of what a typical, mid-range system might cost:

Intra-oral Camera $4000-7000
Digital X-Ray $12000-20000
Extraoral Camera $1000
Imaging Software $2500-5000
Management Software $2000-7000

Of course, this does not include the cost of computer hardware, installation, service and support, materials and disposables, etc. For many of these systems, you will end up paying more for maintenance contracts, upgrades, and materials than you did on the initial purchase. As you can see, it’s not too difficult to equip even a small, 2 operatory practice with just cameras and digital x-rays and spend over $50,000. Again, this leads back to the point made earlier in the article.You must understand that these purchases are investments that will eventually “pay for themselves”.
For the new dentist, financing or leasing of the equipment may make the most sense and will often be the only viable option. There was a time a few years ago when companies were reluctant to extend credit to a new dentist; this, thankfully, is not the case anymore. As with the technology systems, the rate and fees charged by leasing companies can also vary greatly. You should get quotes from national companies, such as HPSC and Matsco, as well as from local leasing companies. Another advantage of leasing is that not only can you have low monthly payments, but also a decision to structure the lease for a fair-market value buyout will lower that payment even more. While owning the equipment at the end of the lease is desirable for many other dental products, you may not want to own 3 –5 year old technology systems when the lease expires. As with most technology, it will change rapidly and many dentists are finding out now that the systems they purchased just a few years ago are now outdated and obsolete.

Space Limitations

Unlike any other profession, dentists are constantly battling the need for more equipment in their workspace with the fact that this space is small! A typical operatory is 10’ X 10’, and when you add in the dental chair, cabinetry, suction/air-water unit, sinks, etc., there isn’t room for a whole lot more. Further complicating the issue is the fact that the equipment must often be placed in very specific positions. The dentist or assistant must easily reach the keyboards for data entry. Any computer monitors that are used for co-diagnosis with a patient must be situated so that both the patient and the doctor can easily view the images. The dentist needs to be aware of how the image will be viewed by the patient when determining correct positioning. For example, a monitor in the upper left hand corner of the treatment room might be an adequate place for the patient who is watching TV or a video, it will not allow the patient to view the level of detail that is needed to co-diagnose dental disease. While there are numerous ways of dealing with these limitations, 3 main solutions have been developed:

1. Use of a cart. The typical cart is designed to be an all-in-one solution, holding a computer, monitor, keyboard, mouse, printer, and often room for another unit, such as a photo printer for intraoral images. While supposedly mobile, I know of few dentists who would enjoy wheeling this contraption from one room to another, especially if the computer is tied into an office network.
2. Smaller components. Perhaps the best illustration of this is a flat-panel monitor, which can easily be attached to a wall or the arm of a light stand. There are also smaller keyboards, and low-profile computers that will help reduce the amount of space that is needed.
3. Wireless computing. New wireless input devices, such as wireless mice, keyboards, and foot pedals can not only allow more freedom on positioning of the equipment, they will also prevent the unsightly clutter of wires and cables that often accompany these complex systems.

Networking Computers

There was a time not too long ago when the idea of placing a computer in the operatory was almost unheard of. Thankfully, computers in the treatment rooms are becoming more and more common.. Many dentists have to come to realize the advantages of having a computer in the operatory to perform basic functions, such as scheduling, treatment plans, and billing. As with many offices, the instructions you give to your assistant for scheduling the next visit with the patient are not always relayed correctly to your receptionist. These errors would not occur if the patient was scheduled while they were still in the chair. In order to function properly, though, the computers in the office must be networked together. There are many advantages to this. A networked computer can have access to all the data from the front office computer, so it can run the practice management program. If the computers are all networked together, then intraoral/x-ray images on one computer will be available to any person on any other computer, allowing the doctor more flexibility in using multiple treatment rooms. Networking will allow you to back up information from one system to another, so that even if one computer goes down, the network will still be able to function properly. Finally, with the importance of online data, networking will allow you to have Internet access from every computer in the office even if you only have one modem or broadband connection.
For the doctor who is building a new office, wiring the rooms for the network before the walls are poured makes the most sense; for most offices, this is not an option. Some considerations that need to be made are the type of wiring and setup of the computers. For most offices, I recommend CAT5 wiring (cable has an end like a standard telephone wire) and a Windows 95/98 peer-to-peer setup. For larger offices with multiple systems, a Win NT/2000 network may make more sense. While these networks can be easy to setup, I would highly recommend that the doctor use an installer who understands networks and knows how to troubleshoot problems.

Software Considerations

There are so many software programs on the market that the choices can sometimes be overwhelming. While recent consolidations have limited these choices somewhat, the process of choosing a good dental software program can be daunting. There are a few guidelines that can be followed to make this choice easier:

1. Make a list of the 5-10 features that are most important to you in a software program. It is well known that most dentists don’t even come close to using even one half of the features of their programs; you should decide what matters most to you and not be swayed by all the bells and whistles.
2. Try to get a demo of the program, either in-office or at a dental meeting. Most sales representatives will jump at the chance to show you what their product can do.
3. Try to get a list of other users, preferably in your area. You should be sure to enquire about frequency of updates, service and support, yearly costs, etc.
4. Service and support should be one of the most critical issues you face. These programs can be quite complex; even the best program won’t help you if it causes conflicts with your systems and the company cannot provide adequate support.
5. Try to work with a consultant or other objective person who can advise you on compatibility issues. In many cases, you will be working with a management program, image manipulation software, and software for controlling the technology devices, …and they all have to work together. Choosing software that has “bridges” to your management program will prevent you from having to re-enter patient information.

The consolidation that has occurred in this field that past few months has drastically changed the dental software landscape. Let me use a recent example to back up this point. Up in the Northeast where I live, there is a company called Intellident that produced a very nice practice management program. Their claim to fame, though, was their outstanding technical support. In a recent survey of dentists performed by Clinical Research Associates, Intellident ranked #3 out of 200 for their technical support. However, in May of this year, Intellident was purchased by Info-Cure and made part of the Practice Works family. There have been confirmed reports that Practice Works has been “encouraging” all Intellident users to switch to their flagship product, Practice Works. While they may continue to support Intellident, this would not make any sense from a business standpoint. A visit to the Intellident web site redirects you to Practice works, so the writing is on the wall for this once fine company. It is because of this that I recommend that dentists consider using a product from a large company if access to service and support is important; examples of these include Dentrix, Softdent, and Eaglesoft.

Computer Hardware

Unlike the choice of a software program, which is often difficult to change, computer hardware is one area that the dentist will be upgrading on a constant basis. Software and technology has continued to evolve; while DOS-based computers were once more than sufficient, they would be woefully inadequate today. Windows-based software, large digital images, network considerations, and complex data management have all pushed the need for faster and more powerful systems. In most cases, the software will determine the hardware that is necessary. I normally recommend that dentists avoid sticking to the “minimum” requirements for a program. Computer hardware has dropped so dramatically in price that there is little justification to using a cheaper and underpowered system. Dentists should also budget for the fact that this hardware will usually become obsolete in 3 years or so as newer and more power-hungry technologies enter the field. One thing I do warn dentists about is purchasing their hardware from software vendors. An orthodontist I consulted with was looking at an ortho software program and the company was suggesting he buy the hardware from them directly. Not only were they recommending a processor that hadn’t been manufactured in over 6 months, but also their systems were priced at three times the retail value for that computer! Many unscrupulous software vendors will tell their clients that they must purchase from a specific manufacturer to be compatible with their system. Of course, this just happens to be the hardware that they sell, and in most cases, it is priced way above market value. Don’t fall for this. Any PC-compatible program will run on any PC-compatible system. I would recommend that dentists purchase their computer hardware either on-line from a major dealer such as Dell or Gateway, from a local computer dealer who allows systems to be customized, or with the help of a consultant/integrator who understands the requirements of the dentist.

One of the ongoing debates in computer hardware revolves around operating systems: PC or Mac? (Linux, a Unix-based system, is making rapid penetration in the business sector, but there are few dental programs compatible with this). There is no doubt that Macintosh computers are attractive and easy to use. There are dental programs that are compatible with the Macintosh operating system. However, I have been cautioning my clients about switching to a Mac system if they don’t already have one. Apple is not the leader in the computer industry as it once was. Their systems are usually a few steps behind the PC in terms of performance, and are typically more expensive than an equally powerful PC. The largest concerns with Macs, though, are the relatively small number of software products available compared to the PC. This isn’t meant to “bash” the Mac systems; I simply feel that with a PC, you have more power, and more choices, at less cost.

The basic rule-of-thumb that I advise my clients is to determine what the most powerful computer is available, then purchase a system that is 2-3 generations earlier than this. For example, the current top PC processor is 1 gigahertz (or 1000 megahertz) Pentium III processor. Moving backwards, the processors manufactured before this were 933, 866, 850, and 800 Megahertz. So, using my recommendations, dentists should be configuring systems with 800 or 850 Mhz processors to get the most “bang for the buck”. Most of these processors were designed to work in large, networked corporate environments; few dentists would be able to push them past their limit.


What About the Internet?

It is still unbelievable to realize that the World Wide Web, as we know it, did not really start until late 1993 and early 1994 with the release of the first web browsers. In just a few short years, the web has become an integral part of everyday life. As is often the case, we dentists are a bit slow to adopt new concepts and paradigms. However, the dentists who refuse to be “online” may soon find themselves being left behind. There are countless advantages of having Internet access in the office, but some of the more important issues are:

1. Access to online ordering of supplies and equipment, which are typically much less costly than traditional channels of distribution.
2. The ability to process insurance claims electronically, which greatly speeds up payment
3. Access to newsgroups, mailing lists, chat rooms, and email which will permit you to share ideas and ask questions of other practitioners
4. Ability to email newsletters and other marketing items to current and prospective patients, at a fraction of the cost of regular mailing
5. A web site that will allow patients to learn more about you, find the office, inform them of payment policies, etc…well in advance of their appointment.

One of the more exciting uses of the web that is rapidly becoming popular in the business community is the concept of Application Service Providers (ASP). To deal with the myriad of problems associated with trying to get shrink-wrapped software programs to be compatible with all computer systems, many companies have solved this dilemma by moving the applications online. In these new systems, you would not go out to purchase a product in the store. Rather, you would go online and download only the products that you need; billing would normally be on a monthly basis or based on which features you actually need and use. One of the more interesting uses of this technology is the advent of online practice management programs. The program files and data would be kept online. There are many advantages to this type of system. Fewer software programs on the computer means fewer conflicts with other programs. The data would be online, meaning that not only could you access it from multiple sites, but also it would be secure and unaffected by any catastrophes to the office, such as a fire. And, unlike most dental software, you could download and pay for only the features you need, contrasting most programs today with features that most dentists will never use. There are currently two online dental software providers, Pack Online (www.packonline.com) and vDentist (www.vdentist.com), but expect others to follow in the next 6-12 months.

Putting it All Together

Perhaps the biggest challenge that the dentist faces is how to integrate all the components successfully. There is nothing wrong with adding technology components to the office one at a time; budgetary limitations might dictate what you can add and how quickly you can add it. For the office that is simply adding a new technology, such as digital x-rays, to their new computer system, this choice is a bit easier; typically, they would simply need to determine which x-ray systems are compatible with their practice management software, and leave it up to the vendor to install and train the staff on the new technology. In many cases, though, this process is quite a bit more complex, involving the need for new computer hardware, networking of multiple systems, transferring/conversion of data, and integration. For this, dentists should work with an integrator who has experience with dental offices. They should understand the space limitations that affect purchases, should have experience and thorough knowledge in computer repair and networking, and be familiar with the dynamics of a dental practice. A technology consultant can assist the dentist in upgrading their software, data conversion, choosing hardware, negotiating prices for systems, and compatibility issues. For the office that is adding multiple technology systems concurrently, a systems integrator is almost a necessity. They can assist the dentist in planning proper locations of the equipment, work with local electricians for installation of cables and wires, test the equipment before it is installed, and act as “quarterback” on installation day to make sure all the vendors and their technical staff are working together.

Conclusion

Technology has become an important component of the modern dental practice. New advances have allowed the practitioner to become more efficient and productive, and have allowed the patient to become a more active participant in the treatment plan. There are a lack of universal standards for these technologies, requiring a significant amount of planning and decisions that need to be made by the dentist. By following some of the guidelines I have mentioned, dentists can make a choice that is best for them and avoid a costly mistake.

About the Author

Lorne Lavine, DMD, A+, N+ practices periodontics and implant dentistry in South Burlington, Vermont. He is a graduate of Boston University, Eastman Dental Center, and the University of Washington. He is an A+ Certified Computer Repair Technician as well as Network+ certified. He is the president of Dental Technology Consultants (www.dtc4u.com), a full service consulting company that assists dentists in all phases of technology integration. For more information, contact him at 866-204-3398