TECHNO BYTES

Use of redundant arrays of inexpensive

disks in orthodontic practice
David Matthew Graham,a Michael James Graham,b and Mel Mupparapua
Philadelphia, Pa, and Cullman, Ala

In a time when orthodontists are getting away from paper charts and going digital with their patient data and im-
aging, practitioners need to be prepared for a potential hardware failure in their data infrastructure. Although a
backup plan in accordance with the Security Rule of the Health Insurance Portability and Accountability Act
(HIPAA) of 1996 may prevent data loss in case of a disaster or hard drive failure, it does little to ensure business
and practice continuity. Through the implementation of a common technique used in information technology, the
redundant array of inexpensive disks, a practice may continue normal operations without interruption if a hard
drive fails. (Am J Orthod Dentofacial Orthop 2017;151:816-20)

O
n a daily basis, orthodontists are relying heavily
on computers for nearly all aspects of their prac-
tices, except where the pliers meet the wire
(Fig 1). However, orthodontists rarely stop to consider
what actually goes into the computers that they have
ordered from a software and hardware support company
or a network that they have cobbled together for them-
selves with off-the-shelf computers from major manu-
facturers. Of course, these computers have all the
necessary parts to function for a number of years before
a critical component finally gives out, but they are not
specialized to meet the needs of a busy office. If a hard-
ware failure occurs in the computer that is the data
server and the component that fails is a hard drive
with all of the critical software and information for the
practice to function, that is a recipe for a bad day. Fortu-
nately, as a responsible adherent to the Health Insurance
Portability and Accountability Act (HIPAA) of 1996, the
orthodontist has a backup, and all patient data are safe
and sound in a secure location.
This scenario may sound familiar to many, and it is
a likely occurrence for any orthodontist who relies on a
computer system for storing and using patient
a
Department of Oral Medicine, Division of Radiology, School of Dental Medicine,
University of Pennsylvania, Philadelphia, Pa.
b
Private Practice, Cullman, Ala.
All authors have completed and submitted the ICMJE Form for Disclosure of Po-
tential Conflicts of Interest, and none were reported.
Address correspondence to: David Matthew Graham, Department of Oral Medi-
cine, Division of Radiology, School of Dental Medicine, University of Pennsylva-
nia, Philadelphia, PA 19104; e-mail, dmgraham@outlook.com.
Submitted, May 2016; revised and accepted, October 2016.
0889-5406/$36.00
Ó 2017 by the American Association of Orthodontists. All rights reserved.
http://dx.doi.org/10.1016/j.ajodo.2016.10.022
816
information for long enough. However, this scenario can
be almost wholly prevented with the judicious use of a
common technology with which any information technol-
ogy support personnel should be familiar: a redundant
array of inexpensive (independent) disks (RAID).
To satisfy federal regulations, such as HIPAA, it is only
necessary to keep an off-site backup and test it regularly
to protect data in case of a disaster.1 Not all disasters
catch the office on fire, bury it under water, or scatter it
across the countryside.2 In an information technology
disaster, such as a hard drive failure in an orthodontist's
data server, access to those data will be completely halted
until the system can be restored, and this must be taken
into account in any responsible practitioner's disaster re-
covery plan. It is imperative to consider the time needed
to restore functionality in an office that cannot access
scheduling, billing, treatment planning, or radiographic
information for the time it takes to get a new hard drive,
install it, reinstall all necessary software, and restore the
data. This could be hours or days, depending on the prac-
titioner's information technology situation.
RAID was first introduced in the late 1980s by re-
searchers at the University of California at Berkeley.3
They sought to improve the performance, capacity, and
reliability of data storage and protection by using multi-
ple hard drives in a variety of configurations to suit
different data management and protection objectives.
In addition to this, their solution was less expensive
than building larger, more advanced hard drives needed
for high performance and capacity of the time—hence,
“inexpensive.” RAIDs are categorized by “levels” 0 through
6 and combinations thereof.3-5
The basis of the different RAID levels is in several data
management techniques: striping, mirroring, and parity.
Graham, Graham, and Mupparapu
Fig 1. A typical computer setup for a small office.
Striping is the process of distributing the data across
multiple storage devices. In this, the data can be divided
up in a number of different sizes (bits, bytes, blocks, or
clusters), making different RAID levels possible.6 Disk
mirroring is simple, and it involves storing copies of
the same information on 2 or more storage devices.3,5
Parity is more complex than mirroring, and it involves
calculating a value from a stripe of data. If part of the
stripe is lost due to a hardware failure, the lost data
can be reconstructed from the parity information and
the remaining information of the data stripe, and it is
the distribution of this parity information across
different hard drives or on a single dedicated hard
drive in a RAID that allows for the information from a
failed disk to be recovered.3,5,7 Because of the differing
uses of these techniques in different RAID levels and
practical financial considerations, only RAID levels 1, 5,
6, and 10 (a combination of RAID levels 1 1 0) are
appropriate for use in a dental practice for practice
continuity and data protection (Fig 2).
RAID 1 is the simplest level, using only mirroring.3,5
In this, the same data are written to 2 or more disks
simultaneously. This RAID level offers increased data
American Journal of Orthodontics and Dentofacial Orthopedics
817
transfer rates when information is being read from the
disks, but it does not differ from 1 hard drive when
information is being written to the disks. Simply, when
1 drive fails in a RAID 1, the others serve as auxiliary
hard drives so that operations can continue as usual
until the RAID can be restored. In its simplest form,
the data storage capacity of the total number of drives
is equivalent to the volume of the smallest drive used
in the RAID.
RAID 10 is a combination of RAIDs 1 and 0. RAID 0 is
not a true RAID, since there is no redundancy, and data
are simply striped across multiple drives.5,8 This means
that all data are lost in case of a hardware failure in a
RAID 0. However, writing information to a RAID 0 is
typically improved over 1 hard drive. Using a RAID 0 in
a RAID 1 configuration means that the drives are
mirrored and then striped. In this way, there is full
redundancy, and this configuration is tolerant of any
drive failure in the array. Additionally, it offers the best
read-and-write performance of any RAID with full
redundancy.5
RAID 5 uses parity information to maintain re-
dundancy of data.3,5,7,8 In this configuration, data are
April 2017  Vol 151  Issue 4
818
Fig 2. For a data set—A, B, C, D—different RAID configurations are shown. Subscript numbers indi-
cate partial information for a piece of data represented by a letter. Parity information is represented by P
with a number denoting the disk with which that parity information corresponds.
striped across all drives involved in the RAID, and parity
information is distributed across all drives. For a number
of hard drives, n, the data storage capacity can be
measured as n–1 (n minus 1), because the equivalent
of 1 hard drive is used to store parity information
across all the disks. If 1 drive fails, the data on it can
be reconstructed from the remaining drives and the
parity information stored on them. This RAID level
offers increased and expandable storage space over a
RAID 1 with the ability to tolerate the loss of 1 hard
drive. Although this configuration can continue to
function for a time after 1 drive is lost, reading the
data stored on the failed disk is significantly slowed.
This is due to the necessity to reconstruct data from
parity information on demand instead of reading the
actual data directly from a disk.
RAID 6 is the newest form of RAID.4 This configura-
tion functions almost identically to RAID 5 with infor-
mation striped across all drives, and double parity
information is distributed across the drives in such a
way as to allow for the failure of 2 drives without data
loss. For this arrangement, the volume of the system is
n–2 (n minus 2), because 2 drive equivalents are used
for the parity information.
DISCUSSION
As more information is stored in a digital format and
orthodontists become increasingly reliant on computers
to aid in nearly all aspects of practice, it becomes impor-
tant to have a plan for data protection in case of a
disaster and a plan for business and practice continuity
if equipment fails. Borrowing from commonly used
terms in enterprise, practitioners need to think about re-
covery point objectives for their data and recovery time
objectives for the business aspect of the practice.2 Fortu-
nately, in the rapidly evolving world of information
infrastructure, there is no lack of options achieve any
April 2017  Vol 151  Issue 4 American Journal of Orthodontics and Dentofacial Orthopedics
Graham, Graham, and Mupparapu
orthodontist's recovery point objectives and recovery
time objectives.
With a recovery point objective, the orthodontist
needs to ask: how much data loss is acceptable and
reasonable? If backups are performed at the end of every
day and carried off-site, there is a possibility that all in-
formation for that day could be lost in case of a disaster
or hardware failure if all data are held on 1 hard drive in
the data server. Although a RAID is not a backup in the
technical sense of the word, it is a backup in the literal
sense. If 1 hard drive fails, others have another copy of
the data from the failed drive or a means to reconstruct
the information. When 1 drive fails, a RAID can function
in a “degraded state” (with the exception of RAID 0) until
it can be restored to full functionality by installing a new
drive and rebuilding the information from the failed
drive. In this, a spare hard drive (ideally of the same ca-
pacity) should be kept on hand, so that the new drive can
be installed in the computer at the earliest available time.
In large, enterprise-grade servers, a “hot spare” may be
kept running in the server and automatically begin the
reconstruction process as soon as a hard drive failure is
detected.9
With a recovery time objective, the orthodontist
needs to ask: how long can my practice-critical systems
be inoperable? With an off-site backup and no spare
hardware on hand, this could range from hours to
days, depending on the practitioner's technologic prow-
ess. It takes time to procure a new hard drive, install and
configure all the critical software for the practice, and
restore the data from backup. Easily, this situation would
take the remainder of the day and, perhaps, a late night
with an enormous amount of unpredictability in the
time it would take to complete each step, depending
on the orthodontist's knowledge of computers and in-
formation systems, availability of the installation files
for the practice critical software, availability of the sup-
port staff from the practice-critical software company,
Graham, Graham, and Mupparapu
and the data transfer speed of the orthodontist's chosen
backup medium and data connectors.
Using any of the RAID levels, the recovery time objec-
tive would be effectively reduced to zero. However, due
to the differing architectures that make each level
unique, array performance will differ. Using a RAID 1
or 10, the performance will be similar to normal in a
degraded state. However, RAID levels 5 and 6 would suf-
fer severe performance penalties because of the necessity
of reconstructing data from parity information instead
of reading it directly from a disk.5 This circumstance
needs to be factored into a decision when selecting
which RAID level is a proper fit for a practice's data
needs.
There is no recipe for choosing the right RAID level
for a practice. Depending on how many digital systems
a practitioner uses, data storage needs can differ signif-
icantly. A completely paperless office with a practitioner
may not fill a hard drive with all the office information,
even using imaging methods with large file sizes such as
cone-beam computed tomography. On the other hand, a
large group practice that meticulously documents
every step of treatment with a full set of photographs
and a 3-dimensional scan of the dentition would likely
exceed the storage capacity of even the most capacious
of drives in a relatively short time. Additionally, the
computer network may be configured in a decentralized
way, with separate storage locations for different kinds
of information, such as business data separated from
imaging data. Taking the unique information technol-
ogy situation of a practice's individual needs is an
important part of the process when deciding which
RAID to use.
In general, measuring data needs in the number of
hard drives is a useful metric. If data storage needs do
not exceed the capacity of 1 drive for the next 5 years
(the average life expectancy for a hard drive), a RAID 1
would easily suit that practice's needs while providing
excellent reliability and some performance gains.10 If
data needs exceed 1 hard drive but not 2, then a RAID
10 can provide even better reliability in some scenarios
than a RAID 1. However, 4 hard drives are needed for
this setup. Once data needs begin to exceed the capacity
of 2 hard drives, the adaptability of RAIDs 5 and 6 is
beneficial until the storage capacity is constrained by
the “nonrecoverable read error rate.”11
Although RAID will be a great benefit to any practi-
tioner, there are some unique problems associated with
it. The “nonrecoverable read error rate” can be under-
stood by knowing that hard drives are not perfect, and
a certain amount of bits per drive will have errors that
prevent the information stored in them from being
read. When the capacity of a RAID becomes great
American Journal of Orthodontics and Dentofacial Orthopedics
819
enough, it is likely that the RAID will have a nonrecover-
able read error while reconstructing a failed drive, poten-
tially leading to loss of the data from the entire array.
Fortunately, technologies such as “disk scrubbing”
have been developed to significantly decrease the likeli-
hood that one of these errors will be encountered.11
Additionally, there may be hardware constraints in the
number of slots available in the actual enclosure for
the hard drives and the number of drives that can be
controlled by a RAID controller (software or hardware
that manages the distribution of data across the drives).
Thankfully, these issues can be resolved through a good
relationship with an information technology support
provider.
In general, the nuts and bolts of information technol-
ogy infrastructure is not a part of dental training. Often,
the knowledge to handle a RAID comes with a degree in
computer science and information systems. However,
since RAID is an extra layer of protection from data
loss and office downtime caused by hard drive failure
that is not governed by HIPAA, some technologically
savvy orthodontists may decide to design and implement
their own RAID. This requires a certain level of confi-
dence and a great depth of knowledge in the intricacies
of hardware, software, setup, and maintenance.
Dentists who may only dabble in information tech-
nology (or to whom the topic is verboten) have a myriad
of options. There are hardware and software support
companies that have been serving dentists for many
years, home-town computer specialists, and big com-
panies whose names are seen every day. These companies
have options available to suit the needs of anyone's prac-
tice. Often, these companies offer service contracts to
have a technician on-site in a matter of hours—any
time of the day or any day of the year—to ensure that
the RAID is fully operational if there is a problem with it.
CONCLUSIONS
Informatics is not a minor part of a practice that relies
heavily on digital data to function. Backups are a stan-
dard way of protecting a practitioner's data, but they
are lacking in the ability to restore a system to function-
ality in a timely manner. Many times, in case of a hard-
ware failure, the office's ability to store data on the failed
system will be crippled during the time it takes to install
a new hard drive, install the necessary software, and
restore the data. Easily, this can take hours to days.
When it comes to practice continuity, the old dictum still
holds true: an ounce of prevention is worth a pound of
cure. For orthodontists who do not want their practices
to be crippled by a fateful hardware failure, the use of a
RAID should be a standard practice.
April 2017  Vol 151  Issue 4
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