Th 0802deradiology


Feb. 1, 2008
Stop procrastinating and make the leap

Stop procrastinating and make the leap

By Paul Feuerstein, DMD Technology Editor, Dental Economics®

What else can be written about digital radiography? We’ve all heard that even though it seems like a large expense, ONCE YOU HAVEIT YOU WON’T GO BACK. Manufacturers say it pays for itself ... patients expect it ... they will get less radiation ... it’s easy to set up ... there’s a simple learning curve ... it’s almost as comfortable as film (who said film was comfortable?) ... it gives better quality than film .... you will diagnose better ... and so on. So why are there still more than 60 percent of offices that do not have digital radiography?

One thing that will push the envelope is a U.S. Government directive, the National Health Information Infrastructure (NHII). A simple Internet search for this agency will give you the details, and we will be expected to have digital or electronic medical records by 2014. This means that patient information will have to be easily exchanged among health-care providers within the bounds of HIPAA. Radiographs surely fall into this arena.

The majority of dental offices in the United States started with film. It is easy, seemingly inexpensive, and the mindset is that anyone with a little training can take a radiograph. You don’t need computers in the treatment rooms (a large expense initially) or any special high-tech training. There are some inherent problems with this attitude. First of all, it is not all that easy to take diagnostic radiographs. Cone cuts, overlaps, over- and underexposure are mainstream and often excused or overlooked. There is surely a learning curve in taking quality images with film, as there is with digital systems. The expense seems like less on a daily basis, but over time the costs add up. You have to factor in time, chemistry (including disposal fees), maintenance of developers, ease (not!) of duplication, cost of mounts, and even the time it can take rifling through a fat chart with years of mounts and envelopes, looking for a specific film. Early film required a larger amount of radiation for exposure. Although digital sensors use less, the differential is closing as new, higher speed film has been introduced. Still, digital systems use less overall.

Let’s look at a typical scenario in a dental office. A patient is appointed for an “emergency” pain on the bottom right quadrant. The assistant typically seats the patient and takes the radiograph. In many offices, since it is an emergency and there is a potential for referral, a double film pack is used to avoid the unpleasant task of duplication later on. The film is developed using quick (wet) developing, and it is brought back into the treatment area.

In walks the doctor, who says, “You missed the apex” or “Get another angle/pick up the tooth in front” or some similar critique. The assistant (now a bit miffed) puts the lead apron back on, retakes the film, crushing it into the patient’s vestibule, and goes off and develops this new film, praying that it will be OK. Lo and behold, the doctor comes in, mumbles a few things, and then, shaking off the liquid, tries to show the patient that there is a widening of the periapical space at the apex of this molar. For drama, a magnifying glass is brought in. First of all, this process can take at least 10 minutes in the chair. Second, even in the best of circumstances, the patient, although politely nodding, does not see this tiny diagnostic issue that took the dentist years of training to decipher.

If this situation occurs in an office with a digital sensor, the entire process takes about two minutes, perhaps even allowing time to start an emergency procedure. In addition, with a 17-inch radiograph on the screen, and software tools such as highlighting magnifiers, the dark apical area is the size of a half dollar. Patients have a better understanding of the problems and, in many cases, the doctor sees things that might have been missed, especially in an example like this one. We have all pondered over minute, suspicious areas on traditional films, squinting, peering, and magnifying with spyglasses or little viewers.

The value of digital radiography is more about its clinical use than in a discussion of maximum megapixels or line pairs. At this point in time we can safely state that all of the commercial digital systems that have survived this marketplace work and are diagnostic. There are surely differences in software, quality of manufacturing, service, support, sensor or phosphor plate design, and even training. It behooves the dentist as well as key staff members to evaluate the system that works best in their hands.

In terms of comfort for the patient, let’s just say that no patient is a big fan of any of this, analog or digital. Companies have tried various approaches to address this. All of the initial systems, with the exception of Dexis, used a film size and shape. The variations are in thickness of the sensors, placement of the wires, and the actual material that the sensor shell was made of. Dexis took a novel approach, reshaped the sensor, and only uses one size. This approach is not without discussion, but the company seems to be fairly successful and has a very loyal fan base.

Others, notably Gendex and Dent-X, have changed a few corners to seemingly add to that comfort zone. The majority use a variety of sensor sizes with variable “live” areas to capture all of the information the practitioner is looking for. Note that the active area is not the same for all sensors, even if the external dimensions are the same. It is important to obtain this information in order to place your sensor in the patient’s mouth to get to the area in which you are interested.

Those who use phosphor plates extol those virtues, such as being able to use multiple sizes, having a little flexibility (although too much of a bend will ruin the plates), and using less bulky positioning systems. If an office is doing a conversion and the providers are “older” (I will have to be PC here), this is often seen to be the easiest transition because it requires little or no training on positioning. If one is setting up a new office and has no film history, this system loses a little of its charm. Of course, the sensor purists laugh at the “slow” development of the plate images. Currently the systems are under 15 seconds (one as fast as four seconds), and for routine full series and bitewings, that does not seem to be a big issue. Some offices use a combination of plates and a single sensor which is used for endo and emergencies. It is amazing how many providers in an office can share a sensor with proper scheduling. It is of course easier to deal with if there are multiple sets of sensors, but in a large office with multiple hygienists, plates can be far more economical. The reason is that each room can house a number of plates that are centrally processed, not unlike the flow of traditional film. The big difference, of course, is that the images come up on the screen in the room and become part of the digital chart. If there is one drawback, it is that the plates have to be wrapped with little barriers before each use – something that can be done in downtime. Replacement plates are under $25 and there is no sensor service contract, although you can get one on the processor/scanner.

Schick has come up with a compromise answer here with the wireless sensor. It comes in two sizes and seems easier to position than the wired sensors, notable with vertical bitewings. It is, however, as bulky and rigid as the wired sensors and still requires a shift in positioning technique. The absence of the wire does allow a little more flexibility in placement of “tough” areas in the oral cavity.

Another benefit of digital radiography is the ability to easily transfer or copy images for someone else. Copying radiographs is one of the least liked tasks in the office. In addition, those of us who have reviewed acetate sheets with images find most of them to be nondiagnostic. When scanners with transparency adapters are used, most offices copy the entire series while still in the mounts. Although helpful, they are not as diagnostic as if they were taken out of the mounts and placed directly on the glass, which is somewhat labor intensive. If these scanned files are sent digitally, the recipient can sometimes tweak the images with digital radiography software. However, they usually print and send them anyway. Again, these printouts can be poor if the resolution and paper are inadequate. Sending a copy of a digital image is simple and far more useful.

One cost factor that enters into this mix is that there should be computers in the treatment rooms. Although there are some sensor systems that can be used with a laptop or tablet computer, the images still have to be downloaded to the central system, which adds another step to the process. In this day and age, it is important to put the computers in the treatment rooms for many reasons other than just DR. In-room scheduling, display of intraoral and digital photo images, as well as patient education are just a few of the reasons to set up this infrastructure. And again, with the impending requirement of digital records, as well as staff harmony, charting treatments and treatment plans from the chairside will keep the front desk free to take care of other administrative tasks. There are some offices that are totally paperless and even “front deskless.” Although very slick, it is not considered mainstream, but a goal of “less paper” is commendable.

What should a practitioner do now? Certainly study the current marketplace and try to get a few in-office demos. The best process is to take actual radiographs on patients and/or staff (or yourself) instead of relying on those that the rep brings. If possible, split the bitewings between two systems, or one system and film on the same side, to get a real comparison and ask the rep to give you a copy of the image. This way you can compare it with another system later on. (This introduces the issue of each company noting that their images look best on their software.) You are looking to see if you can find the DEJ, interproximal caries, and lamina dura on tooth apices. Use the programs and filters to enhance the images, but always be cognizant of the original one. A problem is that most digital systems can change enough of the brightness and contrast, and use proprietary filters to have all images look perfect. As stated above, all of the systems seem to give diagnostic quality images. It is true that some have more resolution in the raw state (line pairs or megapixels), but some of the differences are more technical than actually visible.

Other areas to examine are the support options, warrantees, annual fees, and training. Along with the actual annual support fee, you should determine what exactly is a “covered breakdown” and what the replacement costs will be. The availability of loaners is also important. Many offices shut down their conventional film systems when they go completely digital and cannot afford to wait too long for a replacement. There is one interesting backup system which is a self-developing X-ray film, reminiscent of the old Polaroid instant peel-apart product. It is called Ergonom-X and is available from

Finally, although there is an advantage, it is not essential to keep the digital radiography in the same company as the practice-management software. The advantage is that the images are integrated with the database and the software and “buttons” are embedded in the same screen that the staff is using for all other processes. With a nonmatching DR system, the practice-management system simply uses a “bridge,” which opens up a second program with the digital radiography software and images. They are, however, linked to the patient files, and stored in a different directory. This is an important distinction when it comes to backing up the image – both the PM and DR data must be backed up. Note that the size of this image folder can get into the gigabytes, and along with intraoral and digital camera images, offices can accumulate amazing numbers. Luckily, the cost of storage has come down and there are affordable backup media now in the 500 GB to 1 TB range. The most important point is to be sure you have a backup that is both internal (in-office) as well as external (data removed for the office) on a regular basis. Practitioners who lived through the floods in New Orleans or other catastrophic circumstances, including theft and hardware malfunctions, can attest to the strength of this statement.

If you have been considering the addition of digital radiography, keep all of these ideas in mind. Even if you are in a practice situation where you will be transitioning out soon, this will add considerable value to the practice. Keep in mind that a young practitioner who might be interested in associating or purchasing your practice will have been trained in school or been in other practices where digital is the norm, not the exception. Stop procrastinating and make the leap.

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

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