Dentsply Sirona

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Jeremy Booth, Dental Tribune International

Sun. 8. September 2024

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Change is in the air. In June, Dental Tribune International reported that Dentsply Sirona and Siemens Healthineers had unveiled plans for a dental dedicated magnetic resonance imaging (ddMRI) device for dentistry. The MAGNETOM Free.Max Dental Edition has the potential to allow dentists to visualise inflammation and soft tissue in the mouth without exposing patients to ionising radiation. In this interview, the project’s leading researchers, Prof. Rubens Spin-Neto of the Department of Dentistry and Oral Health at Aarhus University in Denmark and Prof. Donald Tyndall of the Department of Diagnostic Sciences at the University of North Carolina at Chapel Hill Adams School of Dentistry in the US, speak about the new technology and its potential to trigger a paradigm shift in oral care.

Profs. Spin-Neto and Tyndall, what was the direction of the research that preceded this launch?
Prof. Spin-Neto: From our perspective, the research was always focused on making sure this technology was as good as than what is already available and attempting to highlight the potential added values. As researchers, we approached it first and foremost as a modality, asking: What is already available to us now? Can this new modality do the same things? What else can it do—what comes on top? All of our main research questions followed that north star. Of course, where we are at now has raised new questions.

Prof. Tyndall: Any new system needs to have US Food and Drug Administration (FDA) clearance before it can be sold in the US (among others). I have been involved in studies for FDA clearance before, and it is very important that any new system does at least what the current systems do and also what the manufacture claims it can do. What we have been waiting for is the ability to see soft tissue, and one of the expected major added values that we have seen—and we emphasise this—is the ability to see inflammation prior to clinical signs. People are asking me what MRI does that CBCT can’t do. A lot of that has to do with being able to look at inflammation and define its boundaries, being able to see periodontal disease before it manifests visibly in the bone or in CBCT scans of the bone. We have clearly made the case for non-inferiority, and the next step is clinical trials investigating how much better ddMRI is for highlighting pathological conditions compared to radiograph-based modalities.

“We find ourselves at a very important point in the history of dentistry,” according to Prof. Spin-Neto. (Image: Dentsply Sirona)

What types of dental problems could be diagnosed more effectively using the device?
Prof. Tyndall: We see potential for any kind of inflammation, such as periapical inflammation or inflammation in the bone itself. Of course, there is always the differentiation of tumours from cysts, which MRI can do much better than CBCT can. Then there is the temporomandibular joint, where MRI already is the standard of care for temporomandibular disorder problems. ddMRI would be able to help with that. Almost any of the more common dental diagnostic tasks could be met or answered by this technology, as well as looking at fractures of the tooth. It is difficult to see fractures, particularly if a tooth has root canal material in it, and we think that there is a great possibility that MRI will be able to see these as well.

Prof. Spin-Neto: And I think we will be potentially able to anticipate when you see some diseases, because currently we only see many diseases—even clinically—when they are already at an advanced stage. I think we will not only be able to see them, but also see them very early in the onset. So, it could be easier, cheaper and faster to treat these diseases. We always like to talk about dentistry as a preventive medicine, but right now we wait for the problem to be there, and when we see it, we treat it. Using modalities like ddMRI, we can potentially see the problems even before they progress to serious disease. In cases of bone loss around the tooth, for example, if we can see oedema in the bone, that is much easier to treat than bone loss. I think we will be able to act much faster and provide better care.

Prof. Tyndall: Early detection always means better treatment; usually it means fewer treatments, and it can mean no surgery is required.

How do the imaging capabilities compare with those of existing technologies, and what about patient safety?
Prof: Tyndall: Dentists will want to know how much more information this system can provide, whether it will be viable and helpful in their practice, and whether it will help patients. What I tell them is that ddMRI certainly provides more detail about soft tissue. For example, we are starting to produce digital dentures at our school, and the treatment begins with an intra-oral scan, which is quite good but takes a little bit longer. Some colleagues have asked if we can do a CBCT scan and make a digital denture directly from that. Perhaps we could; however, using MRI is something that could be considered. It can provide us with details of bone and soft-tissue thickness and a much better definition of where the muscles are. In the future, digital dentures may be another dental MRI application.

Prof. Spin-Neto: MRI is already much safer because we remove ionising radiation from the equation. Currently, with CBCT, we ask whether the patient will benefit from the risk of receiving radiation in order to detect disease. When this risk is removed, we could say that using dental MRI in a certain population is 100% safe. It then becomes up to the dentist to decide, asking: “Would I need to make use of more resources on this case to improve the treatment or treat the patient in a different way?” In many cases, radiation makes a difference. For example, we would seldom consider follow-up CBCT images, even though we would really like to see bone healing in a patient. I cannot invite a patient for a monthly CBCT—although it would be nice for my research. Some of our patients have been coming in every two weeks for one year to receive follow-up MRIs, because it only takes some  minutes of their time and there is no risk. That is going to teach us so many new things that I feel it will be necessary to rewrite parts of the reference books concerning tissue healing and best clinical scenarios.

Profs. Spin-Neto and Tyndall spoke at the congress of the European Academy of Dentomaxillofacial Radiology in June. (Image: Dentsply Sirona)

Prof. Tyndall: I think that one of the biggest impacts is going to be on the way we treat and manage patients. What we are doing today is not necessarily bad; however, we would like to see this imaging technology not only reveal new information, but also perhaps even change our thinking about how we are treating the patient. Instead of doing it one way, we might be doing it another way. I think that is going to be one of the biggest advantages of this research. Dentistry changed with the introduction of CBCT, and I think that change is going to accelerate with ddMRI.

What are the practical considerations for integrating the unit into a dental school or clinical setting?
Prof. Spin-Neto: The machine already has much lower requirements than medical MRI units do. Medical units require access to and backups for cooling and water and access to helium, which is expensive. The MAGNETOM Free.Max is a closed system and does not depend on external helium. In our school, we tracked how much electricity and water are used per patient, and these are lower compared with a typical MRI unit. The cost per patient is much lower, the footprint is smaller and the requirements for the building are less complicated, aligning with the global push for green technologies.

What about staff required to operate the unit?
Prof. Spin-Neto: Where it gets costly with MRI generally is the need to find personnel. Previously, if a dentist was to consider using an MRI unit, he or she would need a neuroradiologist to help report and a nurse to deal with the patients. Now, idea is that the the dentist can do everything alone, no one needs to inject anything into the patient and the technology does not reveal image structures that dentists cannot report on, because the machine will focus only on the mouth, so we could already save a lot on human resources, and we could also optimise the key measure of time. The patient will not need to change clothes in a special dressing room or talk to a nurse before the scan. These cost-saving factors—calculated over, say, a ten-year period—may bring just as much economy as the machine itself. I have operated the machine by myself on many occasions. The patients come in, and I speak with them, scan them and report on the images. Previously, that was unimaginable with MRI.

Prof. Tyndall: That’s a great point, and one of the big promises of any 3D technology, where the images are essentially constructed using computer algorithms, is, of course, artificial intelligence (AI). AI is going to get better, so I see a road map where there is going to be continual improvement. The question is, how are these improvements going to have an impact on treatment planning? Remember, when we first started with CBCT, we thought it would be used for implants, and now there are so many more uses.

“The question is, how are these improvements going to have an impact on treatment planning?”—Prof. Rubens Spin-Neto, Aarhus University

How might dental MRI further develop in the future?
Prof. Spin-Neto: We find ourselves at a very important point in the history of dentistry. I would describe it like this: Until now, we have been listening to music without all the channels on. Suddenly, as we hear these new channels, we must learn what to do with that extra information. In my lecture during the congress of the European Academy of Dentomaxillofacial Radiology, in June, I mentioned that research shows that dentists have been overtreating up to some 40% of cases, depending on the type of disease. What might that number be if I were to repeat that study now with this new modality? Would it go down to 20% or even 5%? Finding out where we are and further refining the modality is the next step. Of course, we can look at the situation from many different angles. Imagine an insurance agency, for example, wanting to judge whether a dentist has treated the patient correctly. I think we may even have to point the finger at ourselves, saying: “Well, what I did ten years ago would be judged as wrong now, that I can see more, and I know better.” And that is how it should be; we should always be able to do better and find mistakes from the past. The fact remains that we have not developed much in the past 10 years, and this technology is going to change that.

Prof. Tyndall: It is going to be similar to—in fact, greater than—the jump from film to digital images was. Moving to 3D images with the introduction of CBCT was a big enough jump, and this is even bigger. For the future, I would envision a compact unit which can be used on a seated patient, whose whole body we do not need to cover; the system images a certain area in and around the oral cavity. Of course, these units will be at universities, other major institutions, military institutions and large group dental practices. Being of a smaller size will help to democratise the technology. We are also going to see more developments in the software.

Prof. Spin-Neto: If you ask the new version of ChatGPT to create a picture of a dental MRI unit, it can’t, because it does not exist. This technology is changing so many paradigms that even AI cannot predict how it might look or what the next step might be. This shows us that we are really at the limit of what we know. I believe that is a good sign, that we are really pushing the limits of what is possible.