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DIGITAL DENTISTRY IN THE COMPUTER AGE
TECHNOLOGY
STORY
DIGITAL DENTISTRY IN THE COMPUTER AGE TITUS K.L. SCHLEYER, D.M.D., PH.D.
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omputer technology has brought about so many changes in the last 50 years that many people look at the future with a mixture of vague unease and excited anticipation. Considering the extent to which computer technology has changed our lives within the last generation, it is reasonable to ask ourselves,
“What else will the future bring?” Even the most erudite and wellresearched predictions have the tendency to become next year’s humorous anecdotes of computing history. In 1943, Thomas Watson Jr., then chairman of International Business Machines Corp., or IBM, probably formulated one of the most poignant ones when he declared that “I think there is a world market for about five computers.” By the end of 1998, 364 million personal computers were installed worldwide.1
A second issue is that it is becoming difficult to write about any topic with any degree of authority.2 One of the root causes of this problem is that knowledge is being generated and recorded at an exponential rate.3 Much of this information is more accessible than in the past. This phenomenon is producing new approaches to the creation, dissemination and retrieval of scientific knowledge,4-9 but it also makes the job of the author harder. Thus, this article is like a searchlight sweeping through the night. I illuminate some—but, by far, not all—trends in computing technology (for a more detailed
discussion of general computing trends, see Howard10 and Miller and Kirchner11). I then extrapolate some of these trends’ effects on dentistry and detail others that are well underway. I conclude the article by suggesting a few steps that the profession could take to help shape the development and application of technology. Thus, through this article, I hope to stimulate a vigorous discussion of the profession’s future in the digital age. Interested readers are invited to continue this discussion on ADA ONLINE’s discussion forum at “http://www.ada.org”.
ABSTRACT
COVER
Background and Overview. Computers are becoming an integral part of the practice of dentistry. Smaller, smarter and more ergonomic computing devices will support an increasing proportion of dental practice activities. Technology will make practice management more efficient, mainly by reducing transactional overhead. Educational software and intelligent assistants will increasingly support the needs for decision making in clinical practice. Research will benefit from automated tools for data acquisition, management and analysis. Conclusions. Dentistry must actively shape the application of technology. It can do this by developing a cadre of experts in dental informatics, relying on sound research principles, effectively disseminating best practices and developing strategic objectives for the implementation of technology. Clinical Implications. Computer technology is an essential ingredient for state-of-the-art patient care. Dentists must stay current with this rapidly developing field to make appropriate choices in their use of technology.
TRENDS IN COMPUTING
Hardware. Few people foresaw
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COVER STORY that the conceptually simple integrated information access in more places. In fact, circuit one day would play a crucial role in Dick Tracy’s computerized wristwatch many areas of human life. Miniaturization now is a reality. It is called WatchPad and of circuits to date has followed is developed by IBM.14 In the future, we Moore’s Law, which was may use such miniature computing During the 1980s, derived by Gordon Moore in devices either directly or embedded in office workers were 1965 when he was research other appliances. and development director at Networking. “The network is the comhappy just to have Fairchild Semiconductor.12 puter.” Sun Microsystems’ advertising personal computers Moore stated that chip denslogan illustrates how our paradigm of sity—the number of transiscomputing has been turned on its head. on their desks. tors per square inch—seemed During the 1980s, office workers were Today, the network to double at regular intervals. happy just to have personal computers on connection is the Thus, 1975’s 8080 processor their desks. Today, the network connecwith about 10,000 transistors tion is the essential accessory. In addition, essential accessory. has evolved into today’s Penfew people foresaw the transformation of tium III with approximately an obscure research project into today’s 7.5 million transistors. ExInternet,15 which is a global network of sevperts 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 backmeter—wide. bones—high-capacity communication lines Miniaturization and integration, howthat connect regions and countries—per ever, have not been limited to computer month. Today, data traffic and the number chips. Sensors, storage devices and periphof 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 computer currently stores approximately 4 gigabytes (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 possible the existence of personal digital assistants, high-resolution flat-panel screens, subnotebooks and wearable 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, magnifiincreasingly versatile cation ×10 (Andrew Syred, Science Source/Photo Researchers).
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JADA, Vol. 130, December 1999 Copyright ©1998-2001 American Dental Association. All rights reserved.
COVER STORY DENTISTRY Simply download it to your hand-held book21 from your personal electronic literature In the future, library through your cellular interacting with phone. On a busicomputer networks ness trip during your son’s will be as common birthday celebraas using the teletion? Simply join phone is today, but the party through your hotel’s inmore powerful and room videoconfernatural. encing system. Future networks will assume an intelligence of their own. Such “smart” networks will dynamiFigure 2. Visualization of U.S. data traffic over the Internet cally and independently react in September 1991. The colors represent traffic volume ranging from zero gigabytes (purple) to 100 gigabytes to specific situations, much as (white) (NCSA, University of Illinois; Science Source/Photo an experienced taxi driver Researchers). 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 netSoftware. In the near future, software works. Bandwidth is the amount of data will evolve in two major directions. Softthat 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 matheaccess anywhere, anytime are smart matical probabilities to predict outcomes refrigerators that reorder groceries autoand is a method commonly used in artifimatically 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 apprenpoint 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 vercomplex problems to their human countersatile and dynamic. In the future, interparts. 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 developbut more powerful and natural. Forgot ment of the keyboard and the mouse priyour favorite book on a weekend trip? marily was driven by the need for char-
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COVER STORY acter- and pointer-based input. During recent years, speech input has quietly matured into a technology being accepted by mainstream computer users.23 In combination with Dental software domain-specific speech procompanies are cessing applications,24 speech working on recognition can effectively support 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 envi27 way in which ronments will make interacting with computers much practitioners share more natural and convenient patient data. than it is now.
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EFFECTS ON THE PROFESSION
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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 computers in dental practice are becoming reality. The paperless patient record has come to life through smaller, more powerful computing devices and sophisticated software. The fact that it is not in widespread use attests to the multidimensionality and complexity of dental information 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 affordable hard disk. New sensors, laser scanners and intraoral cameras allow us to convert all artifacts associated with traditional patient care documentation into digital form. Where and how we store patient information will become significantly more flexible in the future. Dental software companies are beginning to market Web-based patient records,29 which store patient data on a central Web server instead of on a
computer in the dental office. Dental software 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 dentists already are using the Internet to access diagnostic and therapeutic information, 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 biochemical sensors and probes, simulators, and computer-aided design or computeraided 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 management is the functional area in dentistry 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 communication and scheduling, inventory and supply management, and personnel and financial management.
JADA, Vol. 130, December 1999 Copyright ©1998-2001 American Dental Association. All rights reserved.
COVER STORY DENTISTRY programs available anywhere and at anytime. Dental education and continuing education will be Computer technology reshaped by three trends: increasingly realistic learning can lower practice aids, intelligent tutoring sysoverhead by tems and the merging of learning systems with clinical automating routine decision support. For instance, tasks such as in a virtual reality environ27 sending appointment ment, the human heart can be observed not only statically reminders, but also in function. Such reordering supplies realistic learning systems can make content come alive and and monitoring improve students’ underpractice finances. standing and comprehension. Intelligent tutoring systems will recreate a very effective 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 constantly assess the knowledge and performance of their students, select the appropriate 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 experience. The challenge for informaticians is to devise systems that can effortlessly change shape in an instant—from explaining the details of a therapeutic procedure one moment to helping formulate a differential diagnosis for a patient the next. Research. Computers have Figure 3. A biochemist using a virtual reality system to been an essential tool in investigate molecular interactions (Geoff Tompkinson, Science Source/Photo Researchers). research for a long time. Figure
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Economic constraints may force dental offices to become more automated. In the early 1990s, double-digit inflation of health care expenditures prompted significant 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 monitoring practice finances. Automation may prove to reduce costs, as well as to improve clinical outcomes through systematic, comprehensive and periodical analysis 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 educational 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 prepare teeth with real-time feedback from a computer49 and practice surgical procedures in simulators.50 Distance education makes single courses and whole degree
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COVER STORY 3 shows an example of applied virtualreality modeling that allows researchers to test a variety of theories by manipulating a protein sequence on a Dental informatics is computer. We now are entering an era in which computer proan exciting new field grams will perform much of the that seeks to use discovery for us. Dental materials research already has capiinformation 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 facilidental practice, tates the discovery of previously 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. 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 dissemination. For instance, readers can register their topics of interest with the British Medical Journal and receive an
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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 telecommunication (how information should be transmitted) to create novel solutions to problems in dentistry (Figure 4). To make dental informatics into a core competency and a broad enabling discipline 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-
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.).
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COVER STORY 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 successful computing projects can be tremendous. Best practices and research findings must be disseminated widely and effectively to allow all practitioners to benefit. With the recent establishment of an Informatics and Technology section, JADA has provided an avenue to do so. Develop a strategy and goals to implement 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 standardization.28 The establishment of the ADA’s Standards Committee for Dental Informatics provides dentistry with the opportunity to set standards 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 opportunities that information technology sets out before us. Despite the best-laid plans, however, computing reality has a curious way of surprising us. For example, patients now are beginning to store their own health information on Web servers.63
One reason cited for this trend is that the health care industry has been slow to adopt computers, prompting patients to take matters in their own hands. Patients appreciate that they can make Dr. Schleyer is an their health information availassociate professor able to any health care provider and chairman, Department of with a Web-enabled computer. Dental Informatics, Another caveat is that incesTemple University School of Dentistry, sant and relentless pace of inno3223 N. Broad St., vation should not force us to Philadelphia, Pa. 19140-5096. accept new technologies just for reprint their own sake. Quite a few com- Address 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 information technology will affect the dental profession. The discussion thread is titled “Digital dentistry” and will begin when JADA readers receive this issue. 1. Computer Industry Almanac Inc. Computer Industry Almanac says over 364 million PCs-in-use worldwide year-end 1998. Available at: “http://www.c-i-a.com/199903pcuse.htm”. Accessed Oct. 1, 1999. 2. O’Donnell JJ. Avatars of the word: From papyrus to cyberspace. Cambridge, Mass.: Harvard University Press; 1998. 3. Halperin EC. Publish or perish: and bankrupt the medical library while we’re at it. Acad Med 1999;74(5):470-2. 4. National Library of Medicine. PubMed central: an NIH-operated site for electronic distribution of life sciences research reports. Available at: “http://www.nih.gov/welcome/director/ebiomed/53ebio.htm”. Accessed Oct. 1, 1999. 5. Borchers A, Herlocker J, Konstan J, Riedl J. Ganging up on information overload. IEEE Computer 1998;32(4):106-11. 6. Hersh W. Information retrieval at the millennium. In: Chute C, ed. Proceedings of the American Medical Informatics Association 1998 Annual Fall Symposium, Orlando, Fla., Nov. 7-11, 1998. Philadelphia: Hanely & Belfus; 1998:38-45. 7. Hersh WR, Donohoe LC. SAPHIRE International: a tool for crosslanguage information retrieval. In: Chute C, ed. Proceedings of the American Medical Informatics Association 1998 Annual Fall Symposium, Orlando, Fla., Nov. 7-11, 1998. Philadelphia: Hanely & Belfus; 1998:38-45. 8. Matheson N. Things to come: postmodern digital knowledge management and medical informatics. J Am Med Inform Assoc 1995;2(2): 73-8. 9. Baujard O, Baujard V, Aurel S, Boyer C, Appel RD. Trends in medical information retrieval on Internet. Comput Biol Med 1998;28(5): 589-601. 10. Howard B. Technology on the way. PC Magazine March 25, 1997:142-86. 11. Miller MJ, Kirchner J. Future technology. PC Magazine June 22, 1999:100-48. 12. Schaller RR. Moore’s law: past, present, and future. IEEE Spectrum 1997;34(6):53-9. 13. Mann S. Wearable computing: a first step toward personal
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COVER STORY imaging. IEEE Computer 1997;30(2):25-32. 14. Frauenfelder M. The next great thing. Available at: “http://www.idg.net/crd_1999_79756.html”. Accessed Oct. 1, 1999. 15. Schleyer T, Spallek H, Spallek G. The global village of dentistry: Internet, intranet, online services for dental professionals. Chicago: Quintessence; 1998. 16. Dyson E. Release 2.0: A design for living in the digital age. New York: Broadway Books; 1997. 17. Martin C. Net future: The 7 cybertrends that will drive your business, create new wealth, and define your future. New York: McGrawHill; 1999. 18. Spallek H, Schleyer T. Internet basics. J Am Coll Dent 1999; 66(2):6-15. 19. PC Webopaedia. Bandwidth: PC Webopaedia definition and links. Available at: “http://webopedia.internet.com/TERM/b/bandwidth.html”. Accessed Oct. 1, 1999. 20. AntCam Time Machine. Live Web AntCam. Available at: “http://www.channelu.com/AntCam/”. Accessed Oct. 1, 1999. 21. D’Alessandro MP, Galvin JR, Santer DM, Erkonen WE. Handheld digital books in radiology: convenient access to information. Am J Roentgenol 1995;164:485-8. 22. Teodorescu HN, Mlynek D, Kandel A, Zimmermann HJ. Intelligent systems and interfaces. Norwell, Mass.: Kluwer Academic Press; 1999. 23. Alwang G. Hands-off computing: PC Magazine first looks. Available at: “http://www.zdnet.com/pcmag/stories/firstlooks/ 0,6763,2331859,00.html”. Accessed Oct. 1, 1999. 24. Martin P, Crabbe F, Adams S, Baatz E, Yankelovich N. SpeechActs: a spoken-language framework. IEEE Computer 1996;29(7):33-40. 25. Hedberg SR. MIT media lab’s quest for perceptive computers. Intelligent Systems and Their Applications 1998;13(4):5-8. 26. Shen W, Tan T. Automated biometrics-based personal identification. Proc Natl Acad Sci U S A 1999;96(20):11065-6. 27. Sheridan T, Zeltzer D. Virtual environments. MD Comput 1994;11(5):307-10. 28. Preston J. The practice of dentistry: year 2005—a vision. J Dent Educ 1996;60(1):68-75. 29. Schleyer T, Dasari V. Computer-based oral health records on the World Wide Web. Quintessence Int 1999;30(7):451-60. 30. Collen MF. A vision of health care and informatics in 2008. J Am Med Inform Assoc 1999;6(1):1-5. 31. Frisse M. Healthcare in a networked world. J Am Coll Dent 1999;66(2):51-6. 32. American Dental Association Survey Center. 1997 Survey of current issues in dentistry: Dentists’ computer use. Chicago: American Dental Association; 1998. 33. American Dental Association Survey Center. The 1994 Survey of dental practice: Characteristics of dentists in private practice and their patients. Chicago: American Dental Association; 1994. 34. Schleyer T, Spallek H, Torres-Urquidy MH. A profile of current Internet users in dentistry. JADA 1998;129:1748-53. 35. Schleyer TKL, Forrest J, Kenney R, Dodell D, Dovgy N. Is the Internet useful in clinical practice? JADA 1999;130:1501-11. 36. Worth ER, Patrick TB, Klimczak JC, Ried JC. Cost-effective clinical uses of wide-area networks: electronic mail as telemedicine. In: Reed M, Gardner PD, eds Proceedings of the American Medical Informatics Association 1995 Annual Fall Symposium, New Orleans, Oct. 28-Nov. 1, 1995. Philadelphia: Hanley & Belfus; 1995:814-8. 37. Schleyer T, Spallek H, Arsalan M. Dental resources on the World Wide Web. MD Comput 1998;15(4):252-5,265. 38. Schleyer TKL, Pham T. Online continuing dental education. JADA 1999;130:848-54. 39. Hersh W. Validity and reliability of information. J Am Coll Dent 1999;66(2):43-5.
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40. Jadad AR, Gagliardi A. Rating health information on the Internet. JAMA 1998;279:611-4. 41. Silberg WM, Lundberg GD, Musacchio RA. Assessing, controlling, and assuring the quality of medical information on the Internet. JAMA 1997;277:1244-5. 42. Eysenbach G, Diepgen TL. Towards quality management of medical information on the internet: evaluation, labelling, and filtering of information. BMJ 1998;(317):1496-502. 43. Jenkins RD, Grey-Lloyd J, Hancock C. Medical resources on the Internet: searching and appraising. Hosp Med 1998;59(5):408-10. 44. Smith D. What makes a good web site? Br J Urol 1997;80(suppl 3):16-9. 45. Cunningham S, Tapsall S, Ryan Y, Stedman L, Bagdon K, Flew T. New media and borderless education: A review of the convergence between global media networks and higher education provision. Canberra, Australia: Department of Employment, Education, Training, and Youth Affairs. January 1998. 46. Deden A. Computers and systemic change in higher education. Communications of the ACM [Association for Computing Machinery] 1998;41(1):58-63. 47. Harasim L. A framework for online learning: the virtual-U. Computer 1999;32(9):44-9. 48. Rudin JL. A.D.A.M. (Animated Dissection of Anatomy for Medicine) comprehensive: a computerized human anatomy program. Compend Contin Educ Dent 1996;17(4):344-50. 49. Dentsim. Home page. Available at: “http://www.denx.co.il/ denx25/index.html”. Accessed Oct. 1, 1999. 50. Issenberg SB, McGaghie WC, Hart IR, et al. Simulation technology for health care professional skills training and assessment. JAMA 1999;282(9):861-6. 51. Barnes B. Creating the practice-learning environment: using information technology to support a new model of continuing medical education. Acad Med 1998;73(3):278-81. 52. D’Alessandro MP, Galvin JR, Erkonen WE, et al. The virtual hospital: an IAIMS integrating continuing education into the work flow. MD Comput 1996;13(4):3223-329. 53. Sertgoz A. Finite element analysis study of the effect of superstructure material on stress distribution in an implant-supported fixed prosthesis. Int J Prosthodont 1997;10(1):19-27. 54. Swanson DR, Smalheiser NR. An interactive system for finding complementary literatures: a stimulus to scientific discovery. Artific Intell 1997;97:183-203. 55. Vandre RH, Webber RL. Future trends in dental radiology. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1995;80(4):471-8. 56. Lorenzi N, Gardner R, Pryor T, Stead W. Medical informatics: the key to an organization’s place in the new health care environment. J Am Med Inform Assoc 1995;2(6):391-2. 57. Lipton JA. Research frontiers. In: Abbey LM, Zimmerman JL, eds. Dental informatics. New York: Springer-Verlag; 1992:259-94. 58. Friedman CP. Where’s the science in medical informatics? J Am Med Inform Assoc 1995;2(1):65-7. 59. Patel VL, Kaufman DR. Science and practice: a case for medical informatics as a local science of design. J Am Med Inform Assoc 1998;5(6):489-92. 60. Warner H, Barnett O, Greenes R, Cimino J. A view of medical informatics as an academic discipline. Comput Biomed Res 1993;26(4): 319-26. 61. Comaford C. What’s wrong with software development? Software Development 1995;Nov.:27-8. 62. Diehl M. Strategy for large-scale dental automation. Comput Appl Dent 1986;30(4):745-53. 63. Carrns A. Patients’ next choice: whether to keep files stored on the Internet. Wall Street Journal Aug. 16, 1999:B1.
JADA, Vol. 130, December 1999 Copyright ©1998-2001 American Dental Association. All rights reserved.
STORY
DIGITAL DENTISTRY IN THE COMPUTER AGE TITUS K.L. SCHLEYER, D.M.D., PH.D.
C
omputer technology has brought about so many changes in the last 50 years that many people look at the future with a mixture of vague unease and excited anticipation. Considering the extent to which computer technology has changed our lives within the last generation, it is reasonable to ask ourselves,
“What else will the future bring?” Even the most erudite and wellresearched predictions have the tendency to become next year’s humorous anecdotes of computing history. In 1943, Thomas Watson Jr., then chairman of International Business Machines Corp., or IBM, probably formulated one of the most poignant ones when he declared that “I think there is a world market for about five computers.” By the end of 1998, 364 million personal computers were installed worldwide.1
A second issue is that it is becoming difficult to write about any topic with any degree of authority.2 One of the root causes of this problem is that knowledge is being generated and recorded at an exponential rate.3 Much of this information is more accessible than in the past. This phenomenon is producing new approaches to the creation, dissemination and retrieval of scientific knowledge,4-9 but it also makes the job of the author harder. Thus, this article is like a searchlight sweeping through the night. I illuminate some—but, by far, not all—trends in computing technology (for a more detailed
discussion of general computing trends, see Howard10 and Miller and Kirchner11). I then extrapolate some of these trends’ effects on dentistry and detail others that are well underway. I conclude the article by suggesting a few steps that the profession could take to help shape the development and application of technology. Thus, through this article, I hope to stimulate a vigorous discussion of the profession’s future in the digital age. Interested readers are invited to continue this discussion on ADA ONLINE’s discussion forum at “http://www.ada.org”.
ABSTRACT
COVER
Background and Overview. Computers are becoming an integral part of the practice of dentistry. Smaller, smarter and more ergonomic computing devices will support an increasing proportion of dental practice activities. Technology will make practice management more efficient, mainly by reducing transactional overhead. Educational software and intelligent assistants will increasingly support the needs for decision making in clinical practice. Research will benefit from automated tools for data acquisition, management and analysis. Conclusions. Dentistry must actively shape the application of technology. It can do this by developing a cadre of experts in dental informatics, relying on sound research principles, effectively disseminating best practices and developing strategic objectives for the implementation of technology. Clinical Implications. Computer technology is an essential ingredient for state-of-the-art patient care. Dentists must stay current with this rapidly developing field to make appropriate choices in their use of technology.
TRENDS IN COMPUTING
Hardware. Few people foresaw
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COVER STORY that the conceptually simple integrated information access in more places. In fact, circuit one day would play a crucial role in Dick Tracy’s computerized wristwatch many areas of human life. Miniaturization now is a reality. It is called WatchPad and of circuits to date has followed is developed by IBM.14 In the future, we Moore’s Law, which was may use such miniature computing During the 1980s, derived by Gordon Moore in devices either directly or embedded in office workers were 1965 when he was research other appliances. and development director at Networking. “The network is the comhappy just to have Fairchild Semiconductor.12 puter.” Sun Microsystems’ advertising personal computers Moore stated that chip denslogan illustrates how our paradigm of sity—the number of transiscomputing has been turned on its head. on their desks. tors per square inch—seemed During the 1980s, office workers were Today, the network to double at regular intervals. happy just to have personal computers on connection is the Thus, 1975’s 8080 processor their desks. Today, the network connecwith about 10,000 transistors tion is the essential accessory. In addition, essential accessory. has evolved into today’s Penfew people foresaw the transformation of tium III with approximately an obscure research project into today’s 7.5 million transistors. ExInternet,15 which is a global network of sevperts 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 backmeter—wide. bones—high-capacity communication lines Miniaturization and integration, howthat connect regions and countries—per ever, have not been limited to computer month. Today, data traffic and the number chips. Sensors, storage devices and periphof 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 computer currently stores approximately 4 gigabytes (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 possible the existence of personal digital assistants, high-resolution flat-panel screens, subnotebooks and wearable 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, magnifiincreasingly versatile cation ×10 (Andrew Syred, Science Source/Photo Researchers).
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COVER STORY DENTISTRY Simply download it to your hand-held book21 from your personal electronic literature In the future, library through your cellular interacting with phone. On a busicomputer networks ness trip during your son’s will be as common birthday celebraas using the teletion? Simply join phone is today, but the party through your hotel’s inmore powerful and room videoconfernatural. encing system. Future networks will assume an intelligence of their own. Such “smart” networks will dynamiFigure 2. Visualization of U.S. data traffic over the Internet cally and independently react in September 1991. The colors represent traffic volume ranging from zero gigabytes (purple) to 100 gigabytes to specific situations, much as (white) (NCSA, University of Illinois; Science Source/Photo an experienced taxi driver Researchers). 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 netSoftware. In the near future, software works. Bandwidth is the amount of data will evolve in two major directions. Softthat 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 matheaccess anywhere, anytime are smart matical probabilities to predict outcomes refrigerators that reorder groceries autoand is a method commonly used in artifimatically 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 apprenpoint 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 vercomplex problems to their human countersatile and dynamic. In the future, interparts. 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 developbut more powerful and natural. Forgot ment of the keyboard and the mouse priyour favorite book on a weekend trip? marily was driven by the need for char-
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COVER STORY acter- and pointer-based input. During recent years, speech input has quietly matured into a technology being accepted by mainstream computer users.23 In combination with Dental software domain-specific speech procompanies are cessing applications,24 speech working on recognition can effectively support 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 envi27 way in which ronments will make interacting with computers much practitioners share more natural and convenient patient data. than it is now.
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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 computers in dental practice are becoming reality. The paperless patient record has come to life through smaller, more powerful computing devices and sophisticated software. The fact that it is not in widespread use attests to the multidimensionality and complexity of dental information 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 affordable hard disk. New sensors, laser scanners and intraoral cameras allow us to convert all artifacts associated with traditional patient care documentation into digital form. Where and how we store patient information will become significantly more flexible in the future. Dental software companies are beginning to market Web-based patient records,29 which store patient data on a central Web server instead of on a
computer in the dental office. Dental software 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 dentists already are using the Internet to access diagnostic and therapeutic information, 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 biochemical sensors and probes, simulators, and computer-aided design or computeraided 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 management is the functional area in dentistry 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 communication and scheduling, inventory and supply management, and personnel and financial management.
JADA, Vol. 130, December 1999 Copyright ©1998-2001 American Dental Association. All rights reserved.
COVER STORY DENTISTRY programs available anywhere and at anytime. Dental education and continuing education will be Computer technology reshaped by three trends: increasingly realistic learning can lower practice aids, intelligent tutoring sysoverhead by tems and the merging of learning systems with clinical automating routine decision support. For instance, tasks such as in a virtual reality environ27 sending appointment ment, the human heart can be observed not only statically reminders, but also in function. Such reordering supplies realistic learning systems can make content come alive and and monitoring improve students’ underpractice finances. standing and comprehension. Intelligent tutoring systems will recreate a very effective 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 constantly assess the knowledge and performance of their students, select the appropriate 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 experience. The challenge for informaticians is to devise systems that can effortlessly change shape in an instant—from explaining the details of a therapeutic procedure one moment to helping formulate a differential diagnosis for a patient the next. Research. Computers have Figure 3. A biochemist using a virtual reality system to been an essential tool in investigate molecular interactions (Geoff Tompkinson, Science Source/Photo Researchers). research for a long time. Figure
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Economic constraints may force dental offices to become more automated. In the early 1990s, double-digit inflation of health care expenditures prompted significant 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 monitoring practice finances. Automation may prove to reduce costs, as well as to improve clinical outcomes through systematic, comprehensive and periodical analysis 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 educational 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 prepare teeth with real-time feedback from a computer49 and practice surgical procedures in simulators.50 Distance education makes single courses and whole degree
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COVER STORY 3 shows an example of applied virtualreality modeling that allows researchers to test a variety of theories by manipulating a protein sequence on a Dental informatics is computer. We now are entering an era in which computer proan exciting new field grams will perform much of the that seeks to use discovery for us. Dental materials research already has capiinformation 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 facilidental practice, tates the discovery of previously 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. 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 dissemination. For instance, readers can register their topics of interest with the British Medical Journal and receive an
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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 telecommunication (how information should be transmitted) to create novel solutions to problems in dentistry (Figure 4). To make dental informatics into a core competency and a broad enabling discipline 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-
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.).
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COVER STORY 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 successful computing projects can be tremendous. Best practices and research findings must be disseminated widely and effectively to allow all practitioners to benefit. With the recent establishment of an Informatics and Technology section, JADA has provided an avenue to do so. Develop a strategy and goals to implement 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 standardization.28 The establishment of the ADA’s Standards Committee for Dental Informatics provides dentistry with the opportunity to set standards 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 opportunities that information technology sets out before us. Despite the best-laid plans, however, computing reality has a curious way of surprising us. For example, patients now are beginning to store their own health information on Web servers.63
One reason cited for this trend is that the health care industry has been slow to adopt computers, prompting patients to take matters in their own hands. Patients appreciate that they can make Dr. Schleyer is an their health information availassociate professor able to any health care provider and chairman, Department of with a Web-enabled computer. Dental Informatics, Another caveat is that incesTemple University School of Dentistry, sant and relentless pace of inno3223 N. Broad St., vation should not force us to Philadelphia, Pa. 19140-5096. accept new technologies just for reprint their own sake. Quite a few com- Address 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 information technology will affect the dental profession. The discussion thread is titled “Digital dentistry” and will begin when JADA readers receive this issue. 1. Computer Industry Almanac Inc. Computer Industry Almanac says over 364 million PCs-in-use worldwide year-end 1998. Available at: “http://www.c-i-a.com/199903pcuse.htm”. Accessed Oct. 1, 1999. 2. O’Donnell JJ. Avatars of the word: From papyrus to cyberspace. Cambridge, Mass.: Harvard University Press; 1998. 3. Halperin EC. Publish or perish: and bankrupt the medical library while we’re at it. Acad Med 1999;74(5):470-2. 4. National Library of Medicine. PubMed central: an NIH-operated site for electronic distribution of life sciences research reports. Available at: “http://www.nih.gov/welcome/director/ebiomed/53ebio.htm”. Accessed Oct. 1, 1999. 5. Borchers A, Herlocker J, Konstan J, Riedl J. Ganging up on information overload. IEEE Computer 1998;32(4):106-11. 6. Hersh W. Information retrieval at the millennium. In: Chute C, ed. Proceedings of the American Medical Informatics Association 1998 Annual Fall Symposium, Orlando, Fla., Nov. 7-11, 1998. Philadelphia: Hanely & Belfus; 1998:38-45. 7. Hersh WR, Donohoe LC. SAPHIRE International: a tool for crosslanguage information retrieval. In: Chute C, ed. Proceedings of the American Medical Informatics Association 1998 Annual Fall Symposium, Orlando, Fla., Nov. 7-11, 1998. Philadelphia: Hanely & Belfus; 1998:38-45. 8. Matheson N. Things to come: postmodern digital knowledge management and medical informatics. J Am Med Inform Assoc 1995;2(2): 73-8. 9. Baujard O, Baujard V, Aurel S, Boyer C, Appel RD. Trends in medical information retrieval on Internet. Comput Biol Med 1998;28(5): 589-601. 10. Howard B. Technology on the way. PC Magazine March 25, 1997:142-86. 11. Miller MJ, Kirchner J. Future technology. PC Magazine June 22, 1999:100-48. 12. Schaller RR. Moore’s law: past, present, and future. IEEE Spectrum 1997;34(6):53-9. 13. Mann S. Wearable computing: a first step toward personal
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COVER STORY imaging. IEEE Computer 1997;30(2):25-32. 14. Frauenfelder M. The next great thing. Available at: “http://www.idg.net/crd_1999_79756.html”. Accessed Oct. 1, 1999. 15. Schleyer T, Spallek H, Spallek G. The global village of dentistry: Internet, intranet, online services for dental professionals. Chicago: Quintessence; 1998. 16. Dyson E. Release 2.0: A design for living in the digital age. New York: Broadway Books; 1997. 17. Martin C. Net future: The 7 cybertrends that will drive your business, create new wealth, and define your future. New York: McGrawHill; 1999. 18. Spallek H, Schleyer T. Internet basics. J Am Coll Dent 1999; 66(2):6-15. 19. PC Webopaedia. Bandwidth: PC Webopaedia definition and links. Available at: “http://webopedia.internet.com/TERM/b/bandwidth.html”. Accessed Oct. 1, 1999. 20. AntCam Time Machine. Live Web AntCam. Available at: “http://www.channelu.com/AntCam/”. Accessed Oct. 1, 1999. 21. D’Alessandro MP, Galvin JR, Santer DM, Erkonen WE. Handheld digital books in radiology: convenient access to information. Am J Roentgenol 1995;164:485-8. 22. Teodorescu HN, Mlynek D, Kandel A, Zimmermann HJ. Intelligent systems and interfaces. Norwell, Mass.: Kluwer Academic Press; 1999. 23. Alwang G. Hands-off computing: PC Magazine first looks. Available at: “http://www.zdnet.com/pcmag/stories/firstlooks/ 0,6763,2331859,00.html”. Accessed Oct. 1, 1999. 24. Martin P, Crabbe F, Adams S, Baatz E, Yankelovich N. SpeechActs: a spoken-language framework. IEEE Computer 1996;29(7):33-40. 25. Hedberg SR. MIT media lab’s quest for perceptive computers. Intelligent Systems and Their Applications 1998;13(4):5-8. 26. Shen W, Tan T. Automated biometrics-based personal identification. Proc Natl Acad Sci U S A 1999;96(20):11065-6. 27. Sheridan T, Zeltzer D. Virtual environments. MD Comput 1994;11(5):307-10. 28. Preston J. The practice of dentistry: year 2005—a vision. J Dent Educ 1996;60(1):68-75. 29. Schleyer T, Dasari V. Computer-based oral health records on the World Wide Web. Quintessence Int 1999;30(7):451-60. 30. Collen MF. A vision of health care and informatics in 2008. J Am Med Inform Assoc 1999;6(1):1-5. 31. Frisse M. Healthcare in a networked world. J Am Coll Dent 1999;66(2):51-6. 32. American Dental Association Survey Center. 1997 Survey of current issues in dentistry: Dentists’ computer use. Chicago: American Dental Association; 1998. 33. American Dental Association Survey Center. The 1994 Survey of dental practice: Characteristics of dentists in private practice and their patients. Chicago: American Dental Association; 1994. 34. Schleyer T, Spallek H, Torres-Urquidy MH. A profile of current Internet users in dentistry. JADA 1998;129:1748-53. 35. Schleyer TKL, Forrest J, Kenney R, Dodell D, Dovgy N. Is the Internet useful in clinical practice? JADA 1999;130:1501-11. 36. Worth ER, Patrick TB, Klimczak JC, Ried JC. Cost-effective clinical uses of wide-area networks: electronic mail as telemedicine. In: Reed M, Gardner PD, eds Proceedings of the American Medical Informatics Association 1995 Annual Fall Symposium, New Orleans, Oct. 28-Nov. 1, 1995. Philadelphia: Hanley & Belfus; 1995:814-8. 37. Schleyer T, Spallek H, Arsalan M. Dental resources on the World Wide Web. MD Comput 1998;15(4):252-5,265. 38. Schleyer TKL, Pham T. Online continuing dental education. JADA 1999;130:848-54. 39. Hersh W. Validity and reliability of information. J Am Coll Dent 1999;66(2):43-5.
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40. Jadad AR, Gagliardi A. Rating health information on the Internet. JAMA 1998;279:611-4. 41. Silberg WM, Lundberg GD, Musacchio RA. Assessing, controlling, and assuring the quality of medical information on the Internet. JAMA 1997;277:1244-5. 42. Eysenbach G, Diepgen TL. Towards quality management of medical information on the internet: evaluation, labelling, and filtering of information. BMJ 1998;(317):1496-502. 43. Jenkins RD, Grey-Lloyd J, Hancock C. Medical resources on the Internet: searching and appraising. Hosp Med 1998;59(5):408-10. 44. Smith D. What makes a good web site? Br J Urol 1997;80(suppl 3):16-9. 45. Cunningham S, Tapsall S, Ryan Y, Stedman L, Bagdon K, Flew T. New media and borderless education: A review of the convergence between global media networks and higher education provision. Canberra, Australia: Department of Employment, Education, Training, and Youth Affairs. January 1998. 46. Deden A. Computers and systemic change in higher education. Communications of the ACM [Association for Computing Machinery] 1998;41(1):58-63. 47. Harasim L. A framework for online learning: the virtual-U. Computer 1999;32(9):44-9. 48. Rudin JL. A.D.A.M. (Animated Dissection of Anatomy for Medicine) comprehensive: a computerized human anatomy program. Compend Contin Educ Dent 1996;17(4):344-50. 49. Dentsim. Home page. Available at: “http://www.denx.co.il/ denx25/index.html”. Accessed Oct. 1, 1999. 50. Issenberg SB, McGaghie WC, Hart IR, et al. Simulation technology for health care professional skills training and assessment. JAMA 1999;282(9):861-6. 51. Barnes B. Creating the practice-learning environment: using information technology to support a new model of continuing medical education. Acad Med 1998;73(3):278-81. 52. D’Alessandro MP, Galvin JR, Erkonen WE, et al. The virtual hospital: an IAIMS integrating continuing education into the work flow. MD Comput 1996;13(4):3223-329. 53. Sertgoz A. Finite element analysis study of the effect of superstructure material on stress distribution in an implant-supported fixed prosthesis. Int J Prosthodont 1997;10(1):19-27. 54. Swanson DR, Smalheiser NR. An interactive system for finding complementary literatures: a stimulus to scientific discovery. Artific Intell 1997;97:183-203. 55. Vandre RH, Webber RL. Future trends in dental radiology. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1995;80(4):471-8. 56. Lorenzi N, Gardner R, Pryor T, Stead W. Medical informatics: the key to an organization’s place in the new health care environment. J Am Med Inform Assoc 1995;2(6):391-2. 57. Lipton JA. Research frontiers. In: Abbey LM, Zimmerman JL, eds. Dental informatics. New York: Springer-Verlag; 1992:259-94. 58. Friedman CP. Where’s the science in medical informatics? J Am Med Inform Assoc 1995;2(1):65-7. 59. Patel VL, Kaufman DR. Science and practice: a case for medical informatics as a local science of design. J Am Med Inform Assoc 1998;5(6):489-92. 60. Warner H, Barnett O, Greenes R, Cimino J. A view of medical informatics as an academic discipline. Comput Biomed Res 1993;26(4): 319-26. 61. Comaford C. What’s wrong with software development? Software Development 1995;Nov.:27-8. 62. Diehl M. Strategy for large-scale dental automation. Comput Appl Dent 1986;30(4):745-53. 63. Carrns A. Patients’ next choice: whether to keep files stored on the Internet. Wall Street Journal Aug. 16, 1999:B1.
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