The Future of Digital Radiography

Digital radiography has been available to dentists in this country since 1987. But, according to Dr. John Jameson, less than 25 percent of today's practices use this powerful technological tool.

Featuring Chicago dentist Dr. Claudio Levato

Digital radiography has been available to dentists in this country since 1987. But, according to Dr. John Jameson, less than 25 percent of today's practices use this powerful technological tool. Jameson and Dr. Claudio Levato discuss this technological advancement and its role in dental practices today as well as its potential role in the dental industry nationwide.

Dr. Jameson: Why do you think clinicians are moving so slowly with the implementation of digital radiography?

Dr. Levato: I believe it has been a slow process because digital radiography has been so greatly misunderstood. Initially, there was some overwhelming feeling about the investment made for the value received. Digital radiography first was introduced with Trophy's RVG (radiovisiography) instrument, which required its own dedicated X-ray generator connected to the CCD sensor, with images displayed via a thermal printer. You had to buy the entire kit. In order to implement digital radiography into a practice, the entire system was about a $35,000 to $40,000 investment. The initial image quality pales in comparison to today's quality images. The sensor was the size of a small brick, measuring about 11 mm wide. The instrument was very uncomfortable.

By 1991, the technology had evolved to the next step of offering sensors that could work with your own X-ray heads. All the practitioner needed was the sensor, software, computer and an X-ray generator that had an electronic timer. The electronic timer was essential because the time exposure needed to be reduced. At this time, Gendex of Italy introduced a sensor, and Regam of Sweden and Trophy of France had sensor technology available in Europe. The image quality was better but still not quite what people were accustomed to with film. This is not a very fair comparison since they are two different mediums.

But, in conversations with dentists about digital radiography, it seemed that dentists talked about how great film X-rays are. I found that kind of interesting because, when you talk to insurance carriers, about 80 percent of X-rays submitted are deemed "not legible." So, there's a bit of a double standard there. But, if you were to compare an excellent film image to an excellent digital image, the digital image would still have a lot more diagnostic information available. We have tools that allow us to electronically enhance the image. We're not changing the image so we're not putting in something or seeing something that's not there. Instead, we're able to focus on the different tissues of interest. It is a marvelous tool and the diagnostic applications are phenomenal. A number of prominent radiologists have been recommending digital radiography as the way to go. I think that, with the changes in the dental community at large, we're going to see a greater acceptance of it. So, image quality and diagnostic ability should not be areas of concern. In my opinion, the biggest hurdle today is the misunderstanding of its value.

Dr. Jameson: What is the actual cost to get involved with this technology today?

Dr. Levato: From a standpoint of cost, digital radiography will pay for itself in any dental practice that takes X-rays. Therefore, just to clear that hurdle, you're not going to spend money and never get it back. You have to realize how much money you're spending on film, chemicals, and processor repairs. These are real costs. If you have a digital system, you should have a computer network. Now that we have more and more dentists using computers in their offices, that network is in place for a variety of services and general office efficiencies. The overall cost of digital radiography is reduced since the computer infrastructure is necessary for any practice that wants to function effectively today.

I would say that, for a single dentist working with three chairs without any interest in panoramic X-rays but rather focusing on intraoral images, he or she can implement digital radiography with two sensors, including remotes and software, for approximately $20,000. This does not include computer hardware.

That's not a big investment. It can be further reduced if dentists are combining resources and sharing space. For example, two full-time dentists and a part-time endodontist in a practice with three full-time hygienists and eight chairs can use a hybrid system (combining phosphor plate and sensor technology) for an investment of approximately $50,000. This would cover the cost of the software, a couple of sensors, a laser scanner and the different sizes of phosphor plates. They can maximize the benefits by using sensors for immediate images like endo, emergencies or bitewings, and using phosphor plates for full-series images, panoramics, cephalometrics, etc.

So, there are ways of making the initial investment very cost-effective and, in my opinion, not that overwhelmingly large. I think it's the uncertainty of which system to buy and from what company that concerns dentists. Marketing for digital radiography is rampant, but dentists have not received straight or consistent answers to their questions on the subject.

If you have something in place already, like a practice management program with networked computers, taking the next step is fairly simple. As more and more dentists are making the leap, adding the digital radiography component is not going to be that huge of an investment.

Dr. Jameson: As doctors begin to understand what the investment could be and accept the fact that they are going to have to invest some money into their practice to be able to move to this next level, what benefits can the doctor and team begin to see and anticipate? What significant benefits can dentists realize by having a digital radiography system in their practices?

Dr. Levato: The advantages are numerous. The advantages for the patient include a reduction in radiation and improved patient education capabilities. The biggest advantage to the patient is that, when an image is taken, they're able to see it immediately on a monitor. It's a 17-inch image instead of an image just more than one inch that you have to view through a view box or through the light in the operatory. This enables better communication since the doctor can make specific points while the patient comfortably sees his condition. John, you and I have been practicing for quite some time. I know that I used to take an X-ray and hold it up toward the light in front of the patient and say things like, "See these little dark places on the tooth? That's an abscess." Patients would always nod affirmatively. Now, in retrospect, I wonder how many people really saw what I was pointing at. Today, they're so much more excited and interactive when using digital radiography. The immediate image and big monitor make communication with the patient much more direct and easier.

Dr. Jameson: Yes, patient education is what it's all about and we all know that patient communication involves the entire dental team. What role and responsibility changes within the practice will the doctor need to accept and initiate to make sure digital radiography is implemented for maximum benefit?

Dr. Levato: Cathy (Jameson), your consultants, and you go around the country talking to dentists about communication, teamwork, and building a team of individuals who are committed to providing excellent care for the patient. More and more, I think dentists are realizing that they are not in this alone. Technology will help them delegate a lot of procedures and education must be carried out effectively by every team member. Assistants and hygienists cannot diagnose, but they can certainly take the image and explain what the tooth is, what the bone is, and give patients a general dental geography lesson. So, when the doctor enters, he can make the diagnosis. We have to go ahead and use these instruments, not as tools isolated for one practitioner, but for all individuals dealing with patient education. If you have a computer system, you have all these tools at your fingertips in the treatment room. So, while the doctor is in one room doing a procedure, the next patient is being seated by a staff member. Before the images are taken, the information and education has already started.

Teamwork and education is one aspect, but the other major aspect of the benefit to the doctor is electronic image processing. This is a term Dale Miles uses to describe the tools to extract more diagnostic information from the images you see. Digital radiography will actually make you a better dentist! You will be able to see a lot more. With an image being produced immediately, you can take the image and stay in the room with the patient after no waiting time. Your productivity is going to be enhanced because you're going to be able to save time. Again, what we have so little of is time. When push comes to shove, any technology that can save time in our clinical procedures will pay for itself.

Dr. Jameson: As we begin to see this happening and look at where we are today with the small percentage of dentists who have actually bought into this technology-to be able to save time, to be able to better educate and motivate our patients, to understand the type of dentistry that we're recommending, and the benefits of them receiving it-what do the digital radiography companies need to do to increase their presence in the dental marketplace to make doctors feel more secure in implementing this technology in their practices?

Dr. Levato: I think manufacturers need to look at themselves as resources instead of vendors for equipment. They need to understand what issues dentists have and how products may remedy those issues. The only way to do this is through education. Most of the major companies are keenly aware that they have to tie in some sort of education with their particular products. When there is a software application involved, there are tools and protocols that you have to learn. So, education is critical. You have to teach the team the nuances of taking digital images instead of film images. The training is multifaceted in that you have to train the team about maintenance, proper uses and how to take the images, save them in the proper format, etc. Then you have to offer education to the doctors on electronic image processing. Some might think, "OK, now that I see this image, I can just look at it like I've always looked at it." But, if you plan to get the most benefit from it, it's wise to know how to manipulate the image to extract more data. A long time ago, Miles said something that I still remember. He said that "one good digital image is really comparable to three good analog images." You can take that image and, using contrast, focus primarily on the bone structure. You can go from a negative to a positive mode and that shows the bony trabeculae and the periodontal ligament a little more clearly. If you want to look at interproximal areas of teeth, you can use a technique like embossing to create a three-dimensional look to identify areas of cavitation or marginal discrepancy. There are several tools that make good sense but, if you don't have the technology, you're still working the same way you did when you first started in practice. Education is critical. Companies need to provide programs with continuing education credit because all states require continuing education. This, in turn, will attract the dentists. The companies also could sponsor qualified clinicians to provide didactic information so doctors can learn how to use the tools and the software while company trainers can teach the team how to take good, predictable images.

In our practice, we've been using digital radiography since 1993. I haven't taken a film X-ray since 1994. We have not found any instances in which we needed to use film. If we could not capture an image with a sensor, we would take a phosphor plate or panoramic image. The technology's there and it definitely gives you what you need; you just need to learn to work with it. We need more educational programs out there-no matter whether they are sponsored by dental societies, universities or vendors. That will go a long way to help this technology reach critical mass and become the new standard of care.

Claudio M. Levato, DDS, is a 1976 graduate of the University of Illinois College of Dentistry. He shares a restorative practice in suburban Chicago with his wife, Sharon. Their practice has invested heavily in leading edge technologies during the last 25 years, spanning four computer systems and transitioning different operating systems to create a fully integrated digital patient record. Dr. Levato is also a well-known technology editor and writer and serves as a consultant to the dental trade. He is an active member of the American Equilibration Society, American Academy of Cosmetic Dentistry, an alumnus of the L.D. Pankey Institute, and a Fellow in the International Academy of Dental Facial Esthetics and the Odontographic Society of Chicago.

Dr. John Jameson is chairman of the Board of Jameson Management, Inc., an international dental consulting firm. Representing JMI, he writes for numerous dental publications and provides research for manufacturers and marketing companies, as well as lectures worldwide on the integration of technology into the dental practice, and leadership. He also manages the technology phase of the consulting program carried out by JMI consultants in the United States, Canada, and Europe. He may be reached at (877) 369-5558 or by visiting www.jamesonmanagement.com.

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