Faster than an X-ray, safer than ... well, an X-ray

Aug. 1, 1998
The technology behind the latest generation of radiographs points out a quicker, more efficient way to communicate

The technology behind the latest generation of radiographs points out a quicker, more efficient way to communicate

Ting-Wey Yen, DDS, MS

Diane presents as an emergency and is inserted into an afternoon schedule that is already filled to capacity. Her chief complaint is occasional, spontaneous pain in the area of a crowned tooth.

The assistant seats her in one of the operatories and takes a digital radiograph, lasting 45 seconds. The image appears on the 13-inch monitor within three seconds. The doctor comes in, reviews the radiograph, and notes an apical radiolucency.

He examines her area of concern to confirm the radiographic finding - recurrent caries under distal margin of the crown that takes another 30 seconds. Using the zoom function, he enlarges the image to show the patient the source of her pain, explains his finding, answers all her questions, and refers her to the endodonist. He then writes a short referral note that gets printed along with the radiograph on high-resolution photographic paper, which the patient picks up at the front desk on her way out.

Total chair time: 15 minutes. Total doctor`s time: eight minutes.

In an era when the dentist`s time is increasingly taken up by non-patient treatment - related activities such as management, documentation, dealing with the numerous regulatory requirements, and coping with overhead at an all-time high - chair time is at a premium. Every minute counts. Incredible technological advances help save time and improve patient communication and education.

The intraoral camera and digital radiography have revolutionized the practice of dentistry. At a time when consumers are becoming increasingly health-conscious and insistent on taking an active role in the diagnosis and treatment of their health, education is paramount to the continued growth of the practice. Educational tools that can provide visual evidence are not only helpful in saving time over verbal descriptions, but can provide documentation for future reference as well.

One of the most time-consuming yet essential tasks for general practices is taking and developing radiographs. According to the American Dental Association, the average number of dental visits per week in 1994 was 82.8, or 3,977 annually. If one is to assume that all new-patient visits involve some type of radiographic survey, if not a full-mouth series, and maintenance patients get a bitewing series, the average practice spends an enormous amount of time and money on this procedure.

Traditionally, the time-consuming parts of the procedure are: taking the radiographs, developing and fixing the radiographs, waiting to dry the radiographs (which could be overnight if a tank is employed), mounting the radiographs, maintaining the equipment and solutions necessary for this procedure, and dealing with the proper disposal of the solutions.

This requires a lot of manpower and time. Although automatic processors and faster film have made it easier, taking X-rays is very labor-intensive.

A few years ago, the first major advance towards shortening the process was introduced in the form of electronic sensors. They would capture the radiographic image and transmit it to the computer for viewing, storage, printing, and manipulation. An added benefit was the dramatic reduction in the dosage to the patient - about 10 percent compared to D-speed film. This is especially important to the patients who are very concerned about unnecessary radiation.

As with any new technology, the growth in this industry, which was nonexistent just a few years ago, has been explosive. No less than 10 different companies are vying for the as-yet small market share. Each company has claims to its uniqueness, but all basically share the same principles.

The device consists of sensors of different sizes and shapes, a remote module to transmit data to the computer, and a computer (PC or laptop) with the appropriate capture-card and software. The bells and whistles vary, as do the prices. But as the competition has intensified, the prices have dropped - good news for the consumer.

The comparison of the resolution, accuracy, and quality of different products is not in the scope of this article. Instead, the various uses and benefits of this latest innovation will be discussed from the perspective of a restorative practice.

With the images appearing in less than three seconds, an enormous amount of time is saved with the single images - whether to confirm the seating of a casting prior to cementation, subgingival implant component, or postpreparation. Care must be taken, however, with multiple radiographs because the orientation may not be correct and the image will need to be reoriented once captured. Although it is easy to identify the teeth being imaged, it might get confusing when dealing with multiple implants.

Digital radiography in my practice, which is limited to restorative procedures, has been used to:

- Check for marginal integrity of castings prior to cementation.

- Verify seating of subgingival implant components (abutments, impression posts, or restorative components).

- Verify the proper canal space for posts.

- Use bitewings during follow-up visits.

Other obvious uses for this technology include instant radiographs during endodontic procedures and rapid assessment of the emergency patient.I feel that the time saved, increased patient and staff acceptance, and enhanced educational benefit - as well as the patient`s perception of the technological advancement of the overall office - justify the initial start-up costs. So far the benefits have far outweighed the minor drawbacks. The overwhelmingly positive response from the patients has indicated that digital radiography is the way of the future and here to stay.

In closing, I would like to relay the story of Richard, who accompanied his wife to one of her dental appointments. The wife explained that Richard was very opposed to excessive radiation and has refused attempts by the previous dentist to obtain a full-mouth radiographic survey. As a result, his dental care has been sporadic and only occurs in emergencies.

Richard was introduced to the digital radiography system, and, as an engineer, he was very curious as to how it worked. After the short demonstration and explanation of the greatly reduced radiation dose, he agreed to have several periapical radiographs taken of problem areas. He has since joined the practice. He has also acceded to the request for a full-mouth series.

Digital radiography, along with the intraoral camera, has been a great practice builder - because it is a great communications tool, and greatly reduces the amount of radiation and chair time for the patient.

The advantages

- The speed of the image saves a lot of chair time and is great for assessing the emergency patient, maintenance patient, and patient undergoing an implant, endodontic, or casting sitting.

- There is no need for developing/fixing equipment and solutions, less maintenance, less hazardous waste generated, and less time cleaning and disposing of lead and solutions.

- There is less radiation to the patient and staff.

- The image can be manipulated and modified to be more diagnostic - such as changing the contrast/brightness to enhance the image, thereby avoiding costly retakes.

- It is more educational - such as colorizing to clarify lesions for the patients, or zooming in to a particular area in question.

- You can store and make multiple copies of an image instantly. This is especially important if the patient is being referred elsewhere for additional treatment, or if reports need to be generated for insurance companies, since arrows and areas for notations are easily inserted into the image.

- Measurements can be taken off the radiographs by using a known guide such as an endo file taped to the sensor for calibration. This is very helpful in endodontic and implant evaluations, both in the initial diagnostic phase but also the subsequent follow-up.

- You have the ability to customize templates so that a series of progressive radiographs can be stored and instantly accessed for side-by-side comparison. This is especially useful for long-term follow-up of endodontic, periodontal, or implant areas of interest.

- Microsoft Word can be exported. This is useful for reports and/or presentation.

- You have the ability to be integrated into practice- management systems. More and more practice-management software has the capability to integrate charting, the intraoral camera, and digital radiography into a centralized location.

- You can transmit the radiographic images electronically to other offices. This is especially useful if a multidisciplinary team approach is indicated. It also saves time and postage.

- Large quantities of radiographs can be stored with instant access, thereby minimizing required storage space.

The disadvantages

- A learning curve is involved in the placement procedure. Due to the presence of a wire in most systems, the sensor holders are different from the conventional film holders. The presence of the attached wire in most systems, which has to exit the oral cavity, results in certain images being captured in a reversed or upside-down orientation. The operator must then reorient it.

- Staff has to know how to operate a computer keyboard, be familiar with the windows concept, and get used to working with a mouse.

- Sensors can be bulky. In a small percentage of the patients, especially those with tori, they could be uncomfortable. The manufacturers have responded to the problem by making sensors of varying sizes. As a result, only in a very small number of situations did we resort to conventional film.

- Maintaining a sterile working environment is more cumbersome. This mostly is achieved with the barrier technique (i.e., through the use of plastic sheaths over the sensors and plastic covers over the keyboard).

- Space is required for the necessary hardware in the operatory. Most systems require a computer, monitor, and keyboard, and mouse within the vicinity of the working areas. While the CPU can be tucked inside a cabinet and the monitor can be mounted on the wall, the keyboard may take up valuable counter space unless placed in a drawer.

A cabinet-maker should be consulted to help get the most ergonomic and esthetic placement of the hardware. Please note that some systems can be purchased as stand-alone units. But most doctors, once they are convinced of the time-saving advantages of digital radiography, opt to equip all the operatories, which are linked together in a network.

- As with any new technology, the initial cost can be prohibitive. But with more companies entering the market and the technology entering into the second generation, the prices have become more competitive.

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