FOCUS Orthodontic clinic goes high-tech by Kathleen Moore The impact of computerization in the dental profession has paralleled that of automation in society." (Snyder, 1995) And society has shown that high-volume, repetitive tasks, or mathematical calculations, lend themselves to computerization very well. Society has also shown that decision support systems used in the health care profession are much more complicated. Computer-assisted treatment planning is just now coming into its own, at least at Loma Linda University School of Dentistry graduate orthodontic clinic.   Mark Batesole, DDS, first-year orthodontic graduate student, presents the treatment plan to a patient and her mother. The mother, a radiation technologist, was fascinated with the ZeroBase projections on the computer screen.   When Joseph Caruso, SD'73, MS'75 was appointed chair of the department of orthodontics in 1989, one of his goals was to incorporate digital technology into the educational program. At that time, the driving force was the need to update and rejuvenate lectures, cut down on the time needed to revise academic information, and provide documentation for clinical slides. He knew, even then, that a digital solution to these needs would also necessitate compromise in image quality: a 35mm slide image has a much higher resolution than a digital image. However, the ability to instantaneously update information was, and is, vital. Several faculty members in the department of orthodontics have become proficient in the digital realm. There are those who agree with Dr. Caruso when he says, "You look at your material and you say, 'You know, I don't do that any more' or 'there's no documentation for that so I'm throwing it out.'" And there are faculty who enjoy the shortened turnaround time and their self-reliance when changing their presentations digitally. It allows them to be more current with their information. As the faculty became more digitally-savvy, Dr. Caruso and others realized that having access to the clinical cases treated at the School of Dentistry would provide a huge repository of teaching material. And that would require a computer system capable of storing thousands of records and compressing treatment images. An early computer program used in the orthodontic clinic was written by Gunther Blaseio, MS'86, whose Master's degree project was development of a digitized system of cephalometric analysis. But what that program lacked was some type of database to keep track of all the files, and a true method of diagnostic problem-based analysis. "There was not a computer system out there that was really diagnosis-driven that I had seen. And that was really critical for me," says Dr. Caruso. Then Dr. Caruso met Ivan Dus, MD, DDS, an Italian orthodontist who had studied artificial intelligence programming at the State University of New York at Buffalo. Dr. Dus joined Dr. Carl Gugino to create the ZeroBase Computer Program which was a computerized version of the manual systems developed by Dr. Gugino called ZeroBase Orthodontic Philosophy. The ZeroBase concept is based on a management system-approach in developing a diagnostic and treatment design system that can be expanded upon, based on the patient's individual degree of treatment difficulty. The original theory augmented many principles from Robert Rickett's and Ruel Bench's bioprogressive philosophy. ZeroBase is completely driven by diagnosis and treatment planning. Every time a patient is seen, his/her pictures and/or radiographs are placed into the system either by direct image capture or scanning. The images are compressed to the point that about 4000 patients, with 250,000 images and all the data and letters on that patient, are carried on a laptop computer with about 3.5 gigabytes of memory. Imaging at every or every other appointment allows the orthodontist to quickly review the progress of a patient and visibly see inefficient techniques. However, though imaging is a key factor in ZeroBase, its primary advantage is the logic and complete integ ration of the entire patient management requirements. Like all changes, this change to ZeroBase in the orthodontic clinic hasn't been all smooth sailing. Due to the compression rate, ZeroBase is not able to produce as high-quality hardcopy images as the faculty were used to with 35 mm film. It does make the system more efficient, but there is a tradeoff. Says Dr. Caruso, "It wasn't that the faculty didn't recognize the benefits of it, it's that the faculty also wanted the highest quality printed image. And rightly so. The images were not of the quality we were used to in printed form, so we had to make some adjustments to our thinking." The orthodontic faculty have all come to agreement that the benefits of ZeroBase outweigh the temporary hardcopy image problem that exists with any computer system. With more and more dental offices going digital, there will come a time when the need for hardcopy images will no longer exist. Instead, images will be wired to requesting dentists and viewed as a high-quality screen image. With ZeroBase, faculty and graduate orthodontic students have the ability to pull up any case that is on the computer and manipulate it. A graduate student working on a patient can call a faculty member and discuss the case, with both the student and faculty viewing the case on their respective computer screens. Or, a faculty member can thoroughly review a patient's record before going to the clinic to discuss a needed treatment change. The orthodontic graduate students benefit from using ZeroBase in reinforcing a problem-based diagnostic system in which they have to think through their diagnosis before moving forward. ZeroBase can reinforce to the students a diagnostic discipline that is critical in developing a treatment plan which is individualized and based on the degree of difficulty. This program assists in the decision-making process of the treatment path, and in physically managing the case. An additional benefit is that students will gain diagnostic computer knowledge that will travel with them when they go out into private practice. It will also provide a basis to evaluate other computer programs. ZeroBase stores graphic images such as slides, radiographs, and cephalometric diagrams, which can easily be compared on the same screen, or transmitted to other computers. These photos were sent over the School of Dentistry network as JPEG images, and placed directly into this magazine. The patient is shown in 1992 and 1995 photos for comparison. The ZeroBase computer system offers the advantage to the School of Dentistry of electronic patient information. If oral and maxillofacial surgery needs a radiograph from the orthodontic clinic, that's fine. The radiograph can be transmitted with no need for a hard copy. A future advantage will be to the faculty in developing educational materials. Faculty members can access the clinical case information available throughout the School, as documentation for the academic information being presented. A continuously replenished supply of clinical cases will shorten the time frame needed to create up-to-date lectures. "The progressive dentist [dental educator] can choose from a plethora of technologies that will allow dentistry to be performed more efficiently." (Ellicson, 1995) ZeroBase provides an excellent framework for an educational office environment. Dr. Caruso and his faculty are proving to be leaders in designing decision support systems for orthodontic treatment, in choosing the technologies that best fit the manual system that was already in place: diagnostic-driven bioprogressive treatment planning. References Ellicson, ME. (1995) Abstracted paper. The high tech dental office. Current Opinions in Cosmetic Dentistry. p. 75-79 Snyder, TL. (1995) Abstracted paper. Integrating technology into dental practices. Journal of the American Dental Association. 1995. 126(2):171-178 Kathleen Moore is director of the Dental Alumni Association and Continuing Dental Education in the Loma Linda University School of Dentistry. In addition to working full time, she is a wife and mother, and a graduate student in Health Information Systems in the School of Allied Health Professions, Loma Linda University. 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