Digital imaging - yes!

June 1, 2000
The benefits and advantages of digital radiography made the author go from detractor to supporter of this new technology.

The benefits and advantages of digital radiography made the author go from detractor to supporter of this new technology.

Mike Maroon, DDS, FAGD

When I read the second article in this series by Drs. Thomas Schiff and Jack Hadley, I realized that for dentists to begin to embrace new technology, we have to appreciate all that we`ve learned in the past. Then, we must build on on that knowledge and make a conscious decision to move on into the future.

These are wonderful times to be a dentist! The economy is booming, and more technological advances have been made in the past five years than in the last 50. This also can be an overwhelming time for those of you who would prefer to not "rock the boat."

Why is it that new technology scares people? I may be a different breed, but when I look at something new I get excited for several reasons:

- to see if the technology really works as it should

- to determine if the technology has a place in my practice and my life

- for the opportunity to learn something new

- for the benefits that my patients will receive because of it.

Obviously, getting involved with technology is a personal decision that each one of you reading this article needs to make.

I`d like to take a few of the key points of Drs. Schiff and Hadley`s last article (May 2000 issue) and share my views. For example, they say, "Technology is exciting. It gets people `jazzed.` But that doesn`t mean it`s always a wise investment. Driving a minivan hardly gives the same thrill as tooling around in a sports car. Does that mean the average family should buy a Ferrari?"

I agree with them. The average family shouldn`t buy a Ferrari ... only the person who`s interested in driving a Ferrari! As is the case with automobiles, when you decide to get involved with digital radiography, you will have several choices. You can get the "minivan" version, or you can go nuts and get the "Ferrari."

Measuring value

To measure value in technology, you have to look at not only the tangible benefits, but the intangible benefits as well. I`m sorry to disappoint you, but you will not be the first person to incorporate digital radiography into your practice ... that opportunity is long gone. You are not the "pioneers" of digital radiography. Those practices that have already incorporated digital radiography love the benefits that it provides them. They love the ease of use. They love the quality of the images. They love the storage capabilities. They love the fact that they get instantaneous results. They love the fact that it is safer for the environment. They love the way that information can be shared via computer, e-mail, zip disks, prints, and other media. They wouldn`t give it back!

I`m not here to sell you anything. I was asked to write this article to share my feelings on a wonderful piece of technology. What you decide to do with this information is up to you!

Drs. Schiff and Hadley write, "Here at University of the Pacific, we often consult for dental practices ... When some of these patients come to us, their image records are digital X-rays. In many cases, the quality of these X-rays is terrible. In fact, among referral images, the percentage of direct-digital images that are unusable is far higher than the percentage of truly bad film images."

They continue by saying, "This tells us several things. First, mastering direct digital takes time, attention, and skill. It`s true, as Dr. Maroon points out, that direct-digital system software offers tools like icons and menus that help users manipulate files and images. However, the imaging process itself is far from foolproof. Dentists still must control variables like sensor placement."

Once again, I agree with them to a certain extent. I have been to the University of the Pacific and I know that the computer systems that are in service are older systems. When you get involved with digital radiography, the manufacturers will have minimum suggested requirements for computer systems and monitor resolution to allow you to optimize your results with the program. If you don`t follow their recommendations, your images will not be acceptable. It`s kind of like using old chemicals to process film. You can have awesome positioning of the film, great exposure, a cooperative patient - and still screw it up because the chemicals are old! Digital radiography doesn`t utilize any chemicals - it utilizes computer systems. For diagnostic accuracy, you must follow the recommendations.

It`s also extremely important to control sensor placement, just as you would with regular film. The possibility exists for operator error; however, with digital radiography, you will have an instantaneous result that will allow you to make that determination quicker, saving you time and money. You also will be able to take another exposure immediately, saving the patient the time and expense of another appointment. In addition, it is a fact that there is less radiation to the patient with digital radiography, so you and your patient will have peace of mind knowing that even with a "misfire," the additional exposure is minimal.

Mastering digital radiography will take some time, but it isn`t impossible! Remember back to dental school, when you first learned how to take radiographs and process films? How long did it take you to master that - one week? Two weeks? A month? The majority of offices master digital radiography in a couple of weeks. Practice makes perfect - just like anything else in life.

Here`s a typical scenario in many offices. If it`s a real busy day, the hygienist or assistant will take the FMX or BWX films and not have the time to process them right away. They may even put the films in a labeled container to be processed at a later time when the patient is no longer in the office. Imagine if there is an unacceptable film - and there is bound to be - and now you have to reappoint the patient and waste more of his or her valuable time! Digital radiography, with its instantaneous feedback, will allow your team to be more efficient, thereby improving your overall profitability. Film processing is not instantaneous - it takes time.

Here`s a statement where Drs. Schiff and Hadley lost me completely: "High quality films are available that will let dentists reduce radiation dosages immediately (without converting to a completely new imaging technology). A related point is that when dentists make mistakes with digital, the only option is to retake the X-ray. Needless to say, this can quickly cancel any potential reduction in radiation exposure. Given the fact that, in our experience, more practices are making irreparable errors with digital than with film-imaging, the actual reduction of radiation is probably less than the theoretical reduction."

OK, stay with me here; they say, "When dentists make mistakes with digital, the only option is to retake the X-ray." Excuse me for being confused, but don`t you have to do the same thing with film? I wasn`t aware that was an "error-correcting" film is available that would magically eliminate mistakes from traditional film. The bottom line is when you make a mistake with digital, you have to retake the image and when you make a mistake with traditional film, you have to retake the X-ray. The radiation exposure is less with digital radiography than it is with film, and I`ve already discussed the time-savings benefits. It`s really pretty easy to understand! The positioning of the digital sensor is no different than the positioning of traditional film. It`s actually easier for most practices because of the Rinn-type paralleling devices that practically ensure a good exposure. The only way to take a bad digital image is to violate the principles of image-taking, which is not a good idea in the first place! Follow the instructions and it works.

Drs. Schiff and Hadley say that the exposure reduction is not 90 percent with higher speed films; it`s more like 50 percent. Great! I`ll take the 50 percent radiation reduction for my patients. For some reason, Drs. Schiff and Hadley feel that there are many more retakes needed with digital radiography. They mention it several times throughout their article. Once again, I must reiterate that the majority of people who utilize digital radiography have absolutely no trouble getting correct images the first time. I don`t know where they are getting their numbers from - if they are from the dental school, then the increase in retakes may be because the students are not familiar with the equipment. This is not an issue in the real world of a dental practice.

One of the other potential problems that the doctors are concerned about is, "... the average computer printer is not capable of producing a diagnostic-quality hard copy of a digital image." Not true. Several computers will most certainly produce diagnostic-quality images. Once again. you need to meet the minimum requirements recommended by the digital-radiography manufacturer. Most of the newer generation of printers will print in resolutions higher than 600 dpi, with some going to as high as 1200 dpi and even 2400 dpi. This will absolutely give a diagnostic-quality print image.

The real benefit of digital radiography is the ability to transmit electronic images to other doctors. Most of the programs even have self-viewing files that allow the doctor who receives the image to view it in a "mini-program." This mini-program contains several of the enhancement features that you have on your main system. By using this feature, you can share your images with other doctors and they can see the exact things that you see. Also, you have the ability to annotate the image directly and highlight areas of concern to allow doctors you are consulting with to know your exact concerns. This eliminates the need for duplicating devices, maintaining additional chemicals, envelopes, etc. It also allows you to transfer the image across town or across the world in a few seconds via e-mail - and potentially get an immediate answer. Try doing that with film!

Several of the problems that Drs. Schiff and Hadley mentioned in their May article can be solved utilizing manufacturers` specific recommendations for computer hardware. Many of their concerns come from inadequate hardware. You need adequate processor speed, monitor resolution, and RAM to ensure accurate images. The monitors that provide excellent resolution are not expensive. Most of the newer computer systems have excellent monitor resolution and video cards that will transmit "true color." Once again, it`s not a problem if you follow directions.

Drs. Schiff and Hadley go on to say, "A related misconception about direct digital is reflected in Dr. Maroon`s statement that direct digital `supports a `tremendous dynamic range as compared to film.` It is impossible for this statement to be correct. Consider, first, the meaning of `black` and `white` in an X-ray image. Pure black would represent the portion of an image where enough radiation was detected to convert all the silver to silver halide. Pure white would represent the portion where no radiation was detected. This is simply physics. A piece of film cannot misrepresent total exposure, or zero exposure. So how could a direct-digital image produce `blacker blacks` or `whiter whites?` It`s not physically possible." Digital-radiography sensors are different from film and do not utilize silver halide. They utilize electronics, which can allow for true black and true white colors to be seen, depending on the radiation exposure. This is possible due to the electronics of the sensors. The added benefit is that the digital sensors are not harmful to the environment.

Another benefit is that digital sensors do not get thrown out after every patient. Sure, you have some costs for the patient-protection sleeves and disinfecting solutions. However, you are not throwing out a plastic covering and then having to pay for the disposal and recycling of foil and chemicals.

The point of the matter is: If you want to become involved, you will do your own research and discuss your personal preferences with the digital-radiography manufacturer of your choice. Let the manufacturer know how many treatment rooms you have, what type of computer system you have in your practice, and how you plan on implementing the technology ... then, let the vendor put together a system that fits your needs and price it for you.

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