Digital imaging - not yet!

April 1, 2000
Make an imaging choice that`s right for you. For most general practitioners, film remains the best option. Here`s why!

Make an imaging choice that`s right for you. For most general practitioners, film remains the best option. Here`s why!

Thomas Schiff, DMD, and

Jack Hadley, DDS

Like political debates and opinions about the home team, opinions about film and digital- imaging technologies for dentistry are amazingly susceptible to distortion.

Why is this? A number of reasons spring to mind. First, we tend to be heavily invested - and not just financially - in our technology of choice. Who wants to entertain the notion that any piece of equipment we use everyday - or don`t yet own, but would love to go out and buy - might not be the best choice for our staff, patients, and practice? Compounding this problem is that those who lead the debate often are more heavily invested than the average dentist - and it is human nature to overstate one`s position when the stakes are high!

In addition, not all information that is circulated about imaging technology meets the same standards. It`s often hard to sort the apples from the oranges. As a result, balanced comparisons become extremely difficult. In a perfect world, it would be easy to agree on certain premises, like how much time it takes to process film. But, in reality, a "fact" can be presented in multiple ways, depending on how it is framed.

Consider the "time it takes to process film" question. If you interpret this question as pertaining directly to automatic processor throughput, you get one answer. If you interpret the issue in terms of how long it takes a dental assistant to load a film study on the way to the next operatory where a patient waits to be prepped - plus how long it takes to grab the processed film on the way back from answering the phone at the front desk - you get a very different answer.

Last but not least, there is the equally unrealistic notion that the film vs. digital debate has a single answer. That is no more true for the film vs. digital question than it is in political debates or opinions about the home team. Dental-diagnostic imaging is not a subject that lends itself to a "one-size-fits-all" solution ... and that is not a bad thing! The more choices we have in imaging technology, the more we can refine our menu of imaging services. This is a positive development for the dental profession, because it means we can raise our level of care. If our growing array of imaging choices adds some temporary confusion, that`s OK. We will sort it out.

The key is to make an imaging choice that is right for you and your practice. No one technology can be expected to meet the needs of every dental professional in every situation. It is imprudent to dismiss all digital-capturing technology as overpriced. It is equally ill-advised to assume film will be replaced, because it has been around for so long.

We believe the answer is somewhere in the middle. Dental professionals have to weigh the advantages of each technology and make smart, well-informed decisions. This is why, at our school, we teach digital- and film-imaging. We are preparing our students for the real world - and in the real world, dentists need to make sound decisions based on quality information. In that spirit, let`s consider why film retains its place as the gold standard of dental-diagnostic imaging.

Tried and true

One of the biggest advantages of film is that it has such a long and sound track record. X-ray film technology is more than a century old. Everyone in the industry has experience using it. Any significant kinks were worked out long ago. If a problem with image quality arises, for example, the answer usually is easy to find by making a phone call to the dealer or the manufacturer. The chances that you will encounter something that has never been seen before are virtually nonexistent.

Accompanying the familiarity of film itself is the soundness of the infrastructure that supplies and supports it. Most dental film companies that serve our industry are not technology start-ups. They still may be in business long after anyone reading this article has retired from practice.

This advantage extends to staffing as well. Because film is used universally, dentists generally are spared from having to provide specialized training to their professional employees. Dentists seeking to hire dental assistants or hygienists easily can find qualified applicants who are familiar with film and film- processing.

With digital X-ray systems, the converse often is true. Dental schools such as ours have begun to maintain digital-radiography equipment that we use to train our dentists. In fact, we believe that training future dentists on such equipment is an extremely important part of their professional preparation.

However, until this equipment also is standard at institutions that prepare assistants and hygienists, the supply of dental staff, well-trained in digital-radiography technique, will remain small. It is likely that this situation will remain quite pronounced in rural areas and less affluent communities for many years to come.

Other advantages of film

Film`s history provides other advantages as well. Because of film`s long track record, dentists can be confident that they understand its costs. It is common knowledge that using dental film requires the purchase of a processor (which may be in service for decades), film, and chemicals. Occasional service calls might be needed during a processor`s lifetime. Other than that, there are usually few surprises.

With digital systems, on the other hand, we have only begun to understand the true costs, including both capital and operational expenses. Contractual arrangements for system maintenance, for example, can add significantly to the cost of digital systems. Yet, not all dentists realize these systems` maintenance requirements or consider maintenance costs as part of their digital X-ray-system investment. Until the digital systems have been around long enough for such costs to become common knowledge, dentists should gather and analyze cost information with great care. In most cases, it is likely that using film systems are, over time, less expensive.

Still improving

Although dental film has a long history, it has not remained a static technology. T-Grain Emulsion technology, which Eastman Kodak Company developed, is an example of a more recent dramatic improvement in film technology. Originally, all silver halide grains were pebble-shaped. Kodak, however, found a way to "flatten" them. Flattened grains collect light more efficiently. This, in turn, enabled Kodak to create faster films which lower radiation dosages significantly without compromising image quality and resolution.

Manufacturers of dental-film products appear to be committed to improving the quality of film and to reducing the required radiation doses needed to expose it. It is no stretch of the imagination to believe that the image-quality standards set by film will continue to rise.

A film in the hand . . .

Another advantage of film is that it is an extremely stable diagnostic record. We have film studies on file in our office that date back as far as the 1930s, and they are as readable today as they were 70 years ago.

Digital X-rays, however, are stored electronically, which raises some questions about their longevity. Today`s image files could be rendered obsolete as technology changes. An example of this can be found in the world of personal computers - today`s systems are not equipped with disk drives capable of reading 5.25-inch floppy disks. Any data we stored on these disks is essentially lost. The possibility that this might happen to today`s digital X-ray images does exist.

A corollary to this argument is that film is relatively low-tech. It doesn`t require practices to install computers or hire computer-savvy staff.

Being low-tech provides another advantage as well - the chances of technology-based failure is lower. Should an automatic processor fail, films still can be processed manually. Compare this to the prospect of a digital X-ray-system failure - the system goes down and all diagnostic imaging stops. It is for this reason that we predict that, for the foreseeable future, even practices that purchase digital systems will maintain, or arrange access to, film and film- processors. They will need film as a back-up system should their digital systems fail.

Another advantage of dental film is that it is more comfortable for patients. Digital X-ray sensors are more bulky and rigid than film packets. Some patients may find them uncomfortable.


Film also is a highly versatile diagnostic record. Practices that originate studies on film have many choices in the handling and use of their images. They can use film as a stable and tangible long-term record. They also can easily scan the image to digitize it for filing insurance claims or supporting referrals. For many practices, this option provides the best of both conventional and digital-imaging worlds.

Proven image quality

Finally, the fact is that film studies support excellent image quality. In addition, there is a lower risk of losing image information between exposure and viewing. With digital images, there always is the chance for image degradation. A compression algorithm might compromise final image quality. A lower-quality computer monitor might impact the diagnostic efficacy of the digital file. With film, on the other hand, the data you capture is the data that you see on your view box.

Situations certainly exist when digital-image capturing may make sense. Real-time imaging during surgical procedures, for example, may be of use to endodontists. But for general practitioners, film remains the tried and true standard for diagnostic imaging. This may change one day. But film`s strengths virtually guarantee it will be the imaging tool of choice for many years to come. Furthermore, we would recommend that practices that do choose a digital system keep a film-based system on hand to act as a back-up in case the digital system goes down. The reliability of film remains a critically important asset for the vast majority of practicing dentists.

For more information about this article, contact Dr. Hadley at [email protected] and Dr. Schiff at [email protected]. A biography of the authors appears on page 12.

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