Digital radiography has a legitimate ROI

March 1, 2005
In the first installment, we determined that digital radiography - or DR - has arrived, is affordable, and has a legitimate return on investment. Now, let’s examine specifics.

By Paul Feuerstein, DMD

Computer infrastructure

To view radiographic images, a computer monitor is necessary. This leads us to believe that offices must have computers in the treatment rooms. Since many offices are not ready to do this, many doctors assume digital radiography is not an option. Although putting computers in treatment rooms certainly is the best option, alternatives exist. The simplest method to operate software and show images is via a laptop or tablet computer. This portable solution allows the sensor to be attached to the mobile computer and capture, manipulate, and store images. It is technically possible to store these images on a server or front-office system, but this requires a connection to the network. This can be done using a cable from the laptop or tablet to the network hub (directly or through a wall outlet) or using a wireless connection. The advantage of centralizing the data is that it allows the practice-management files to have some integration with the radiograph images. (I will address integration later in this article.) A few DR companies sell entry-level, yet high-quality “complete” systems that include a laptop or tablet.

If an office decides to add digital radiography to an existing computer network or install a new one, a few things need to be addressed in the treatment room computers. You must check the connection requirements from the sensor company. Many use USB connections. This might seem to be a simple, portable solution that allows sensor sharing among many rooms - after all, you should be able to plug and unplug the sensor into the USB port - but it’s not that simple. Many computers have inaccessible USB ports in back. Some have ports on the front, but if the computer is inside a cabinet or in an odd location, this also proves impractical. You could get a powered USB hub, a small unit that comes with a 6-foot (or longer) wire and allows the USB outlet to be placed in a more accessible location. This assumes the sensor plugs directly into the USB. In many cases, the sensor plugs into a junction box that plugs into the USB outlet on the computer. Manufacturers supply these, and one is necessary for each room. The boxes range from $500 to $1,500. Some companies use other types of connections which should be installed in the computers being used. Many of the companies will supply you (for a fee) with the properly tested components. Check this specification with each manufacturer to ensure a smooth installation.

X-ray machine

Contrary to perception, the digital sensors can be used with most existing heads. Images will be OK, but it will be difficult to tweak or calibrate the sensors to their fullest capacity.

According to Dr. Dale Miles of the University of Arizona, “Most X-ray machines have inaccurate timers, a higher than needed kV setting, and are AC- (alternating current) type generators that produce a more heterogeneous X-ray beam which works less well with contemporary sensors. We are always loath to change anything that works in our office, but in the case of your X-ray generator, it may be time to upgrade your X-ray equipment.”

This has to be considered in your budget if you are upgrading in an office that has older heads, even if they still seem to work just fine.

Phosphor plate systems

One overlooked digital radiography system is the Phosphor plate digital system. This allows the office to use reusable plates that resemble traditional X-ray film. These plates are put in various types of plastic barriers and placed in the mouth the same way film is used. Then, they are put through a digital developer (actually a scanner), and in as little as five to 45 seconds, the images can appear on the screen. Once the image is available, the software can manipulate and store the images in the same manner as the wired sensors. These plates are erased and rebagged before using them on the next patient. Note that although they are flexible, they cannot be bent as much as traditional film. Since they cost about $25 each, they can be replaced inexpensively in the event of scratching, over bending, or other damage or loss. There is a degradation of the image after many exposures (50 to 500, depending on the company’s claims), but it is still inexpensive to keep several on hand. Many offices use the phosphor plates for routine recall bitewings and full series, but keep a wired sensor for emergencies, endo, surgery, and other circumstances. The phosphor plate systems claim to be as comfortable as film. Dale Miles replies, “Who said film is comfortable?” The sensor companies have worked hard on their design to deal with this perception.

A hybrid solution is available from Schick Technologies. They have developed the only wireless instant sensor in the marketplace. This sensor is the same speed and quality as their wired unit - it comes with a receiver that is connected to the computer. Although this unit comes at a premium price, several practitioners prefer its flexibility.

All-in-one systems

A few companies have arrived in the digital radiography marketplace with integrated solutions. Let’s say, for example, that Sears decided to sell an integrated TV system. They could go to Sony for the TV, Panasonic for the DVD, and Samsung for a receiver. Then, their engineers would make sure the system worked in harmony, set up one remote, and sell the entire package as the Sears Home Entertainment system. They would service, sell upgrades, and warrant the product. This has happened in the digital radiography marketplace. Several companies use sensors from one company, software from another, and do the fine tuning and customizing in a total package. These companies did the homework for you. This also gives smaller companies a chance to gain a competitive edge. There also are independent sensor makers that stand alone and develop their own hardware and software, such as DEXIS. These systems are maintained and upgraded by the manfacturer, but with the proper software can work with all available practice-management systems. Another permutation are companies such as Suni, which sell stand-alone systems but also license hardware to other companies as part of all-in-one systems.

Integration with practice-management software

This is one of the most confusing areas of the digital experience. Many of the major practice-management systems companies are in the sensor business and make things easy for offices looking for a total solution. It is not essential to have all parts coming from the same vendor. Many of us have DVD players and TVs. If you have, for example, a Sony TV and a Sony DVD player, you will find that the remote control from one will operate both. If your DVD player is Panasonic, you find yourself shuffling two remotes - the two components still work fine, but they’re just a bit cumbersome. Third-party companies make programmable remotes. Using a few steps and codes, you can control both units from one device. Using this analogy, look at the options offered.

Stand-alone solution

No matter which practice-management system you use, one option is to use independently the software that comes with the sensor. In this scenario, when using the sensor, the software is opened, patient information is entered, and radiographs are taken and stored in the software’s database. These images either can be stored in the hardware device being used for capture (laptop, tablet, or treatment room computer) or centrally in a file on the server.

The upside is that this software usually is designed by the sensor manufacturer and takes maximum advantage of enhancement features of the images. Note that some systems use programs such as Tigerview or Apteryx instead of developing their own for stand-alone use. It is essential to know where that data is stored in order to properly back up that data.

The downside of this setup is that there is a redundant set of patient data files, and patient information has to be entered manually. This is similar to using two remotes as in the previous example.

Bridge - one way

In this scenario, the sensor software is used for taking and storing the images, however, the patient data is captured with a bridge program. This means that the practice-management program is opened to a patient file. Then, the sensor software is opened through a button or icon in the practice-management software (or maximized from an icon in the taskbar where is has been resident) and essentially reads the name and other information of the open patient. The operator does not have to enter the patient name or other information. One bridge is called “name grabber,” which does exactly that. The images are taken but still stored in the sensor database. This is invisible to the operator and does not add any noticeable time. Once the images are stored in the sensor database, they will open every time that patient is called up in the practice-management software.

The downside is that there are two database files that have to be maintained and backed up. The sensor software support and upgrades are handled by that company, while the practice-management software has its own maintenance fees. Support problems have a minor potential for finger pointing by two companies. Also, either party might impose fees to make this bridge available. Still, it offers a solution for the practice that wants to use one company’s practice-management software and another’s sensor system. This is similar to the third-party programmable remote in the previous example.

Direct integration

This setup allows the practice-management software to acquire the images directly. The practice-management software usually has an imaging module that can capture, manipulate, and store the digital radiographs. In some cases, this is simply built into the software by the sensor manufacturer in the same company. The programmers are working under the same umbrella making this seamless. This is the example of the Sony TV and the Sony DVD player using the same remote control. The other thing behind the scenes is that the images are saved in the same database as the patient information, thus there is one data backup file.

There are also blends of these scenarios where there is great cooperation between the sensor company and the practice management or even other company’s capture software. Although the practitioner must know which setup is being used, the end result is that almost all sensors can be used with all software. It might be necessary to have a third-party integrator involved in your office setup to make this all work properly if you are using multiple vendors.

Next month in the final installment, I will examine some clinical applications, summarize the workflow, and get some user and expert opinions on this technology. What are the questions to ask and how should an office go about making a decision? Also, we will take a peek at the digital radiography crystal ball.

Dr. Paul Feuerstein installed one of dentistry’s first computers in 1978. For more than 20 years, he has taught technology courses. He is a mainstay at technology sessions, including annual appearances at the Yankee Dental Congress, and he is an ADA Seminar series speaker and technology editor for Dental Economics. A general practitioner in North Billerica, Mass., since 1973, Dr. Feuerstein maintains a Web site ( and can be reached by email at [email protected].

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