Artificial Intelligence (AI) is the ability of machines to perform tasks that normally require human

intelligence. AI is not a new term, the concept of AI can be dated back to 1950. However, it has
not become a practical tool until two decades ago. Owing to the rapid development of three
cornerstones of current AI technology—big data (coming through digital devices), computational
power, and AI algorithm—in the past two decades, AI applications have been started to provide
convenience to people's lives. In dentistry, AI has been adopted in all dental disciplines, i.e.,
operative dentistry, periodontics, orthodontics, oral and maxillofacial surgery, and
prosthodontics. The majority of the AI applications in dentistry go to the diagnosis based on
radiographic or optical images, while other tasks are not as applicable as image-based tasks
mainly due to the constraints of data availability, data uniformity, and computational power for
handling 3D data. Evidence-based dentistry (EBD) is regarded as the gold standard for the
decision-making of dental professionals, while AI machine learning (ML) models learn from
human expertise. ML can be seen as another valuable tool to assist dental professionals in
multiple stages of clinical cases. This review narrated the history and classification of AI,
summarised AI applications in dentistry, discussed the relationship between EBD and ML, and
aimed to help dental professionals to understand AI as a tool better to assist their routine work
with improved efficiency.
Clinical Application of AI in Dentistry
Radiology
CNNs have shown promising ability to detect and identify anatomical structures. For example,
some have been trained to identify and label teeth from periapical radiographs. CNNs have
demonstrated a precision rate of 95.8–99.45% in detecting and identifying teeth, almost rivaling
the work of clinical experts, whose precision rate was 99.98%.8,9

CNNs have also been used for the detection and diagnosis of dental caries.10 In 3000
periapical radiographs of posterior teeth, a deep CNN algorithm was able to detect carious
lesions with an accuracy of 75.5–93.3% and a sensitivity of 74.5–97.1%. This is a considerable
improvement over diagnosis by clinicians using radiographs alone, with sensitivity varying from
19% to 94%.11 Deep CNNs have great potential for improving the sensitivity of dental caries
diagnosis and this, combined with their speed, makes them one of the most efficient tools used
in this domain.

Orthodontics

ANNs have immense potential to aid in the clinical decision-making process. In orthodontic
treatments, it is essential to plan treatments carefully to achieve predictable outcomes for
patients. However, it is not uncommon to see teeth extractions included in the orthodontic
treatment plan. Therefore, it is essential to ensure that the best clinical decision is made before
initiating irreversible procedures. An ANN was used to help determine the need for tooth
extraction before orthodontic therapy in patients with malocclusion.12,13 The four constructed
ANNs, taking into consideration several clinical indices, showed an accuracy of 80–93% in
determining whether extractions were needed to treat patients’ malocclusions.12,13

Periodontics
According to the 1999 American Academy of Periodontology classification of periodontal
disease, 2 clinical types of periodontitis are recognized: aggressive (AgP) and chronic (CP)
forms.14 Because of the complex pathogenesis of the disease, no single clinical,
microbiological, histopathological or genetic test or combination of them can discriminate AgP
from CP patients.15 Papantanopoulos and colleagues16 used an ANN to distinguish between
AgP and CP in patients by using immunologic parameters, such as leukocytes, interleukins and
IgG antibody titers. The one ANN was 90–98% accurate in classifying patients as AgP or CP.
The best overall prediction was made by an ANN that included monocyte, eosinophil, neutrophil
counts and CD4+/CD8+ T-cell ratio as inputs. The study concluded that ANNs can be employed
for accurate diagnosis of AgP or CP using relatively simple and conveniently obtained
parameters, such as leukocyte counts in peripheral blood.
Various non-surgical and surgical methods have been devised for the treatment of periodontally
compromised teeth (PCT) and supporting structures.17 Despite advances in treatment
modalities, no significant improvement has been made in the method for diagnosing and
predicting the prognosis of PCT. Clinical diagnostic and prognostic judgement depends heavily
on empirical evidence.18 Lee and coworkers19 evaluated the potential utility and accuracy of
deep CNN algorithms for diagnosing and predicting PCT. Using the CNN algorithm, the
accuracy of PCT diagnosis proved to be 76.7–81.0%, while the accuracy of predicting the need
for extraction was 73.4–82.8%. The noted difference in accuracy seemed to occur between
different types of teeth, with premolars more accurately diagnosed as PCTs than molars
(accuracies were 82.8% and 73.4%, respectively). This could be explained by the fact that
premolars normally have a single root, whereas molars have 2 or 3 roots, thus exhibiting a more
complex anatomy for a CNN to interpret.

Endodontics

Although mandibular molars tend to have similar root canal configurations, several atypical
variations may occur.20 To minimize treatment failures related to morphological differences and
to optimize the clinical outcomes of endodontic therapy, cone-beam computed tomography
(CBCT) has become the gold standard. However, because of its higher dose of radiation
compared with conventional radiographs,21 CBCT is not used systematically. To overcome such
challenges, AI has been introduced to classify the given data using a CNN22 to determine
whether the distal root of the first mandibular molar has 1 or more extra canals. Radiographs of
760 mandibular first molars taken with dental CBCT were analyzed. Once the presence or
absence of the atypia was determined, image patches of the roots obtained from corresponding
panoramic radiographs were processed by a deep-learning algorithm to classify morphology.

Although the CNN had a relatively high accuracy of 86.9%,20 several limitations exist regarding
its clinical integration. The images must be segmented manually,23 which consumes a
considerable amount of time. Furthermore, the obtained images must be of adequate size and
should focus on a small region to allow the system to concentrate on the object being studied,
while covering enough area to include pertinent information.24
Oral Pathology

Detection and diagnosis of oral lesions is of crucial importance in dental practices because early
detection significantly improves prognosis. As some oral lesions can be precancerous or
cancerous in nature, it is important to make an accurate diagnosis and prescribe appropriate
treatment of the patient. CNN has been shown to be a promising aid throughout the process of
diagnosis of head and neck cancer lesions. With specificity and accuracy at 78–81.8% and
80–83.3%, respectively (compared with those of specialists, which were 83.2% and 82.9%
respectively), CNN shows great potential for detecting tumoural tissues in tissue samples or on
radiographs.25,26

One study used a CNN algorithm to distinguish between 2 important maxillary tumours with
similar radiologic appearance but different clinical properties: ameloblastomas and keratocystic
odontogenic tumours.26 The specificity and the accuracy of diagnosis by the algorithm were
81.8% and 83.3%, respectively, comparable with those of clinical specialists at 81.1% and
83.2%. However, a more significant difference was observed in terms of diagnostic time:
specialists took an average of 23.1 minutes to reach a diagnosis, while the CNN achieved
similar results in 38 s.26
The current use of AI in dentistry
At this stage, the main use of AI in dentistry seems to be as a diagnostic aid for detecting a
number of pathologies on 2D and 3D x-rays including but not limited to dental caries and
periodontal disease and/or bone loss.

The different companies using AI in dentistry currently can be broadly broken up into 2 groups –
those that only read 2D X-rays such as bitewings and OPGs and those that have 3D x-ray
(CBCT) capabilities.

The 3D x-ray group consists of:

Diagnocat
Relu
Promaton
Velmeni
Dentbird
Ceppro
Orca
The 2D x-ray group consists of:

Pearl
Apteryx
V7Labs
Denti.ai
Overjet
VideaHealth
What is quite fascinating is how all these different companies try to capture market share.

On one hand, you have Pearl AI by talented clinician Dr Kyle Stanley. He leads arguably the
most popular dental AI company that has FDA approval in the USA (the world's largest digital
dentistry market by a large margin). Pearl is doing some fascinating things with AI in terms of
optimizing patient bookings and recalls when hooked into your practice management software.

Overjet and Videahealth have 510(k)s approvals for caries and radiographic bone loss and
Denti.ai has one for auto charting. Companies such as Henry Scheinhave actually embedded
Videahealth's AI functionality into both their Dentrix and Ascend software and include their
FDA-cleared functionality in their diagnostic workflows.

Other companies such as Diagnocat which is led by Alex Sanders have taken a different
approach with the focus almost completely being on 3D x-rays.

His software was one of the first to enable fully automated and AI-driven segmentation of facial
bones, x-rays, and now even airway spaces and sinuses. This is one of the ways I heard about
the software as it was a very handy tool for people who wanted individual STLs of each tooth.

Diagnocat is next moving into the field of automated and AI-driven implant surgical guide
creation and aligner treatment.

An example of Diagnocat Software shown above

It's incredible to think about where the future of dentistry is headed.

For instance, CAD is a factor that scares a lot of dentists and is likely a major barrier for many in
adopting chairside 3D printing.

Here is a scenario - with AI and other software out there, it is not too much of a stretch to
imagine getting a patient who may need an implant, taking a CBCT, uploading it to AI software,
getting back a surgical guide design almost instantly, checking and confirming the design, and
then printing all within 30 minutes.
AI in CAD/CAM not just diagnostics
Other companies are going into the dental prosthetic space such as DentBird which seems to
provide a completely cloud-based CAD solution. After uploading scans, the AI can detect
margin lines and provide a CAD design of your choice. Currently limited to single units but
without a doubt with enough time and resources, this could be extended to almost all indications
in dentistry.

AI is also being incorporated by some established big digital dentistry players.

It's not just the scanner companies that are having all the fun. 3D printer company SprintRay
has also shown comparable foresight to 3Shape. Their RayCloud software offers a number of AI
features including a completely AI-based night guard design. Although it definitely needs a bit of
work, it's a step in the right direction.