The Impact of Dental Artificial Intelligence for Radiograph Analysis

Artificial intelligence (AI) is transforming dental care. Natural language processing applications can analyze unstructured data, including clinical narratives and chart notes. Computer vision and machine learning algorithms can aid in radiograph interpretation after models have been trained to identify tooth structures, restorations, root canal treatment, caries, calculus, periapical radiolucencies, and bone level measurements, as well as other pathological indicators and anatomical features.

Dental AI software can analyze and annotate radiographs in near real-time, transforming traditional gray-scale images into a color-coded diagnostic adjunct designed to draw the eye to potential pathologies. AI analysis is directional, not diagnostic. For example, depending on the AI provider, the technology can detect, outline, and color incipient and non-incipient carious lesions (Figure 1).The dentist still determines the appropriate treatment following clinical examination of the patient and with consideration given to other clinical aspects of the patient's dental and medical history.

In the following case examples of dental AI usage, the clinical leaders of two large dental support organizations (DSOs), a small dental group, and a private practice share their experiences with implementing AI for radiograph analysis and clinical insights. In all cases, the desired outcome was to improve communication with patients and deliver better patient care.

Great Lakes Dental Partners is a DSO with 35 practices in the Midwest. With a philosophy of providing convenient, comprehensive care, the group has general dentists and specialists at its practices. It is a doctor-led organization, and many of the providers were involved in vetting various dental AI solutions, according to Charles Zasso, DDS, MBA, the Chief Dental Officer at Great Lakes Dental Partners.

"The software has to help the clinicians do their jobs," Dr. Zasso says. "We began by showing them the technology to see if it would make their day easier and help them with patient care. We started with four locations and gathered feedback from the doctors. We had training and consistent follow-ups with the team. We tracked usage to ensure people gave it a fair chance. With all of that, we found that adoption was high."

The AI that Great Lakes Dental Partners selected automatically analyzes and annotates radiographs, reviews radiographs from prior visits going back 18 months, cross-references the AI findings with the treatment plans in the practice management software, and displays findings on a daily patients' dashboard (Figure 2). According to Dr. Zasso, the AI-powered analysis and annotations help the DSO in multiple ways:

●   It quickly, clearly, and consistently indicates clinical findings on the radiographs, which enables the doctors to make better clinical decisions.

●   It simplifies communication with patients because they can see the quantification and color-coding added by the AI (Figure 3 and Figure 4), which helps them better understand their oral health.

●   It helps the revenue cycle team with insurance claim submissions.

●   It provides detailed insight for the company leadership team so they can design education support and tracks for recently onboarded doctors.

●   It helps the practices organize their day by using the information provided on the daily patients' dashboard during morning huddle meetings.

●   It annotates radiographs from prior appointments, identifying potential treatment opportunities for the doctors to review.

Providers, according to Dr. Zasso, say the AI gives them more consistency and helps improve patient outcomes. "It also saves time and reduces the decision fatigue you can have looking at different gradations of gray on an x-ray. It's objective. The AI will give you the same results, regardless if it's the Friday of a holiday weekend or the Monday morning after the Super Bowl," he comments.

He adds that even doctors who are excellent diagnosticians say the AI helps them communicate with patients. "It gives them a beautiful aid. It colorizes the decay and shows where the decay has penetrated through to the dentin. This helps patients understand the urgency and the priority of why treatment is being recommended. When patients can see the decay and other findings clearly displayed, it helps them co-discover and take an active role in their health."

Reich Dental Center has three practices in Georgia and plans on adding more in 2023. Owner and founder Robin Reich, DDS, is a practicing dentist with six associates. With 36 years of experience in dentistry, she also coaches doctors through Fischer's Professional Group and has served as president of the Georgia Dental Association and Chairman of the American Dental Association Council on Communications.

Dr. Reich's philosophy is, "If your office is not well run, you cannot provide the quality dentistry you would like," and she believes in staying current on what's happening in the industry. "I evaluate new technologies, but I don't adopt until I'm convinced the technology is equal to or better than what I already have," she says. "It's got to have value for our patients and our practice."

Reich Dental Center implemented AI for radiograph analysis and clinical insights during the summer of 2022. One of the driving factors was the desire for clinical consistency and alignment.

"We have multiple providers and we want to have consistency among them," Dr. Reich says. "Now we can make sure we're all seeing the same findings. We may not have the same treatment plan, but it is comforting to know the AI is helping to identify where there is decay. Even if I was a solo provider, I would use AI because it clarifies what I'm seeing. The other doctors feel the same way."

Dr. Reich says the rate of adoption varied at first, with some providers being excited about using AI and others wanting to naturally resist and stay with what they were familiar with. Noting that it can be challenging to push a staff forward to use new technologies, she points out that, "Once a few of them got on board and saw the benefits, they began advocating for it. When other people saw it being used with relative ease, they started using it, too. The providers like when the AI confirms what they're seeing, and they can feel more confident about treating or not treating."

At one of the Reich Dental Center practices, multiple providers share an office. Dr. Reich says they often pull up the AI findings on the radiographs and discuss possible ways to treat the conditions.

"All dentists, regardless of experience level, may at times miss decay or question whether what they see on an x-ray is decay," she says. "AI is a partner in the process of evaluation. Doctors want to diagnose accurately and they like having the AI findings to guide them to review areas of concern."

Private practices are adopting AI technology as well. Scottsdale Smile Center has been serving the Scottsdale, Arizona, community for 40 years. Brandon Ryff, DDS, is the current owner, with three dental associates, two of whom are prior owners of the practice.

According to Dr. Ryff, their trend has been toward digitizing dental workflows, from digital imaging to electronic health records to intraoral cameras and scanners. Scottsdale Smile Center added AI-powered clinical insights and radiograph analysis in 2022.

A persistent problem led the team to investigate adding AI. "Sometimes we can see decay clinically, but may miss it on the radiograph. We wanted AI technology to reduce false-negatives," Dr. Ryff says. He notes the importance of being able to spot decay early, when it is small, so that treatment can be less invasive and the problem easier to address.

Dr. Ryff reviewed US Food and Drug Administration documentation available publicly¹ and selected an AI provider that had analyzed more than 7,000 tooth surfaces and showed that when dentists used AI, they were able to detect 32% more tooth surfaces containing caries (according to an internal study from Overjet, Inc.). According to Dr. Ryff, it is not the quantity of surfaces detected that is ultimately important, but the improved quality of care that is able to be provided. He adds that detecting caries when it is small improves clinicians' ability to apply noninvasive treatments that are less costly with fewer adverse effects for patients.²

"Sometimes I'll look at an image without the AI, and I don't know if I would have caught the decay," Dr. Ryff says. (See Figure 5 and Figure 6.) "[The AI] draws your attention to an area that you might miss, and then you use your training to evaluate that piece of information and determine whether it is appropriate to move forward with treatment or not."

When evaluating which AI technology to bring into the practice, Dr. Ryff involved the other doctors and the team in the decision-making process, believing doing so would increase the chances of obtaining buy-in. "Everything comes down to value. If the team doesn't see the value [in AI], then you can't expect them to help the patients see the value," he says.

Training was key to the successful implementation of AI into the diagnostic workflow, Dr. Ryff says. "It's not a ‘one-and-done' training. We talk about the AI findings and share in the morning huddle how it helps us better diagnose and reduces the chances of overlooking something. Not using this technology is a missed opportunity to protect patients."

Dr. Ryff concludes by suggesting that AI also helps his team educate and motivate patients toward their optimal oral healthcare. Using AI tools to educate patients and show them what's happening in their mouth instead of just telling them helps them understand the problem and the proposed solution, and they are more likely to accept treatment, he offers.

Patient education is key to success at Jefferson Dental & Orthodontics, says Ankoo Raina, DMD, the Chief Clinical Dental Officer of the group's 74 locations. Since implementing visualization tools, including AI for radiograph analysis and intraoral scanners, the company's case acceptance has doubled.

Calling the feedback she gets from providers "amazing," Dr. Raina says the quantification that the AI adds makes it easier for patients to understand the condition of their oral health. "They learn that it's not just that they have bone loss, but how much bone loss there is. Showing the patients the numbers is a game-changer. They also see the decay and how deep it goes. It takes the doubt away. Seeing is believing," she says.

Adding AI for radiograph analysis has also aligned the company's providers, reducing friction between providers and specialties. "Each doctor's training and philosophy guide their diagnosis," she emphasizes. "But having AI provide objective data helps standardize the treatment protocols, which leads to better clinical alignment and a better patient experience."

Rolling out a new technology to more than 70 practices requires a lot of communication, Dr. Raina has learned. Jefferson Dental & Orthodontics started by making sure every team member understood how the AI technology would benefit patients and make their own jobs easier. The company conducted training and created a feedback loop to identify any concerns and address them. The AI training was incorporated into the company's onboarding process, and a clear standard was set that AI is part of patient protocols, she explains.

"It improves the dentistry, the clinical alignment, and the quality of the conversations with patients about their oral health. Once the team saw that, it was easy to gain adoption," she concludes.

Artificial intelligence for radiograph analysis is a compelling tool for providers to aid in creating an accurate diagnosis and effectively communicating with patients. It creates an objective, unbiased review of the radiographs, and the presentation of the information enhances patient treatment discussions. AI also helps calibrate providers to facilitate clinical alignment and consistency. Additionally, clinical leaders report that it helps with the professional development of associates by drawing their attention to areas on radiographs that may need closer examination and reinforcing their diagnosis.

As with any technology, successful adoption depends on the doctors and team understanding the benefits that AI brings, the quality of the training, and the ease of use. Properly implemented technologies such as AI augment not only the doctor but the whole team. The benefits from the efficiencies and automation that are built in ultimately result in more time to improve patient outcomes and communicate more thoroughly with the patients.

Robert J. Kolts, DDS, MBA
Clinical Director, Overjet, Inc., Boston, Massachusetts

Christopher M. Balaban, DMD, MSc
Vice President of Clinical Affairs, Overjet, Inc., Boston, Massachusetts; Clinical Faculty, Boston University Goldman School of Dental Medicine, Boston, Massachusetts; Private Practice, Boston, Massachusetts; Fellow, American College of Dentists

Charles Zasso, DDS, MBA
Chief Dental Officer, Great Lakes Dental Partners, Chicago, Illinois; Fellow, American College of Dentists

Owner/Dentist, Reich Dental Center, Smyrna, Georgia; Past President, Georgia Dental Association

Brandon Ryff, DDS
Private Practice, Scottsdale, Arizona

Ankoo Raina, DMD
Chief Dental Officer, Jefferson Dental & Orthodontics, Dallas, Texas

1. Food and Drug Administration. FDA K212519. Overjet Caries Assist. https://www.accessdata.fda.gov/cdrh_docs/pdf21/K212519.pdf. Accessed November 30, 2022.

2. NPT Innes, Schwendicke F. Restorative thresholds for carious lesions: systematic review and meta-analysis. J Dent Res. 2017;96(5):501-508.