April 2015
Volume 36, Issue 4

The “Inevitability” of Digital Radiography in Dentistry

Claudio M. Levato, DDS; Allan G Farman, BDS, PhD, MBA, DSc; and Dale A. Miles, BA, DDS, MS

What factors should dentists consider when updating their practice to digital radiography?

Dr. Levato

Digital radiology has matured over the past several decades,1,2 and technological innovations continue to increase clinicians’ options for implementing digital imaging into their practices.3,4 With the advent of cloud-based practice management (PM) systems that have digital radiology applications combined with USB-wired and wireless sensors, handheld x-ray generators, and laptops or tablets with USB ports, digital radiology can be mobile and versatile enough to individualize these applications in ways that are as unique as the dentist’s imagination.

Unlike the past 40 years of dental practice, dynamic changes are happening in the traditional dental ecosystem. It is an industry that is highly insurance driven, many new dentists are mired in debt, and there is an ever-growing corporate model of dental practice. These factors accentuate the need for existing practices to be technologically current, not only to maintain patients and attract new ones, but to position themselves for transition or sale when retirement comes. The market value of the non-digital practice will decline as the marketplace extols the benefits of digital patient records.

Incorporating digital radiology into a practice requires an objective analysis of its existing condition. Is current infrastructure sufficient or inadequate? Number of providers? Number of treatment rooms? Age of hardware and equipment, and is there a replacement plan? Facility size and lease? Relocation plans? What is the budget for digital radiology system purchase, maintenance, support, and training? What are the redundancy requirements for back-up and replacement for repair or failure? Hardware and software support? Other or future applications desired, such as extraoral and 3-D imaging?

Once a practice knows where it is, it has to decide where it wants to be. The digital radiology system is merely one aspect of the practice that must work synergistically with the PM system and computer network infrastructure. It is important to research and evaluate more than one system, securing detailed estimates for the necessary hardware, software, installation, training, and support. If a computer network already exists in the practice’s operatories, the quality of imaging should be tested on that existing equipment. The final image attained is affected by the hardware used, which, if dated, may not yield an acceptable image.

The optimal digital imaging solution should: have seamless integration with the practice’s digital patient record; be accessible with other images for correspondence, referral, and treatment planning; and be available from any workstation or mobile device.

Finally, the staff should be involved in the entire process. If they are excited about the technology and understand its benefits, it will become a positive factor in building your practice.

Dr. Farman

Just as one would be unlikely to buy a new car without first test driving it, clinicians should inspect digital radiography purchases in a similar manner to the extent possible. Whether converting from an analog environment to digital or upgrading from an older digital system to a newer one, or whether examining a small system such as an intraoral x-ray sensor, which should be done in the familiar confines of your dental office, or a larger system, which can be observed in a practice where it is already being used, the clinician needs to scrutinize the acquisition carefully in relation to his or her specific practice and clientele. 

A seamless integration of the new technology while still being able to access existing patient data is an important consideration; so is the ability to integrate image and metadata files from the new technology with the existing practice management system and records. Also critical is the support for future operating system updates. For digital systems, a long-term support agreement with the manufacturer is advised, with the availability of remote support that is provided under a HIPAA confidentiality agreement. This is especially key for “big ticket” items such as cone-beam computed tomography (CBCT).

Intraoral x-ray digital sensor technology has matured to the point where image quality is now more than sufficient for standard dental radiographic tasks. The author recommends that the system come from a company that has been in the business for at least a decade. Most importantly, the user should be comfortable with the software, including reading, exporting, and importing standard DICOM format images. Also, sensors should be able to reach the mouth of the patient seated in the operatory. For panoramic systems, additional considerations are the added value of such capabilities as being able to adjust the image layer to more accurately represent the patient's anatomy and the possibility of special orthogonal projections permitting better clarity of posterior teeth. Such programs can be useful when placement of intraoral sensors is problematic due to trismus or severe mucosal ulceration. CBCT inclusion or upgradability might also be considered.

Purchasing a CBCT system presents additional issues. The cost is highly predicated on the size of the detector even though such costs have been on the decline. You should know the field of view needed for the tasks to be performed in the office and purchase no more than what is needed. Most dentists and dental specialists will be able to meet all their imaging needs with a medium or small field of view. Moreover, don’t expect to build an imaging center and receive large numbers of outside referrals, because in many communities today there are ample systems being used. In certain instances, the CBCT system will need to be accredited in order to receive insurance payments.

Regarding radiation dosage, if treating children, the systems purchased should provide pediatric exposure protocols that child-size dose. Users can pledge to “Image Gently” at the Alliance for Radiation Safety in Pediatric Imaging website (www.imagegently.org). Remember that digital radiology is not necessarily lower dose than analog imaging; doses depend on the settings applied in the office irrespective of whether digital or analog film is used. Indeed, CMOS (complementary metal-oxide semiconductor) and photostimulable phosphor systems have wide recording latitudes, and excellent images can be achieved with a broad range of exposures. When purchasing, inquire about mechanisms that can be supported by the system manufacturer to reduce any unnecessary overexposure.

Dr. Miles

Back in 2000 I wrote about digital radiography and its inevitability in dentistry. Fifteen years later, here we are addressing the same issue. Perhaps it wasn’t as inevitable as thought! Yet, after continuing to thoroughly research digital imaging and its impact on dental practice, this author still believes that the transition to a digital environment, although somewhat intimidating, is inescapable.

It’s now a digital world, and dental practitioners need to transition to digital technology in order to communicate efficiently and professionally with patients, colleagues, and specialists. The “digital essentials” that practitioners need are: networked computers; practice management (PM) software; clinically useful peripheral devices that integrate easily with the PM software; an understanding of digital technology, including terminology; and knowledge of electronic image processing (EIP).

Today, there are a number of significant advances compared to 15 years ago. The first of note is solid-state technology—that is, wired digital sensors (solid-state detectors) that use either CMOS or CCD (charge-coupled device) technology and which have become very affordable. Indirect digital receptors, correctly called photostimulable phosphor plates (PSPs), have also improved. Phosphor plates, however, still take more exposure time for a diagnostic image compared to solid-state detectors and require more careful handling. They have utility in both the endodontic and pediatric specialties.

Second, today almost all practices have computers and use them for PM activities. The cost for these devices is reasonable, however up-to-date software must be maintained for both the operating system and the PM and imaging requirements.

Third, monitors used chairside are now a key component of digital dentistry. A quality monitor should be a high priority, as this is where diagnostic decisions are contemplated. The author suggests a high-resolution monitor with high contrast and a small pixel pitch (0.26 mm or smaller). A separate grayscale monitor could also be considered for viewing just radiographic images.

Fourth, while manufacturers are providing improved training for dental staffs in terms of image acquisition, this has not been the case for doctors for the use of EIP. Doctors may be shown a wide array of image processing tools, but little training is being provided regarding which tools should be used for which diagnostic tasks. This is an area where the dentist must seek out additional education.

Fifth, x-ray equipment must be updated. The timers on a machine that is 10 to 15 years old cannot be expected to be accurate when asked to perform for only 0.04 seconds for an anterior exposure. Updating to a direct-current (DC) generator, preferably with variable kilovoltage peak (kVp), is advised. Staff should be trained to use different exposure times for various sized patients.

Sixth, consider a multifunctional panoramic machine for much of your image acquisition. This technology has matured substantially and, in some cases, can actually substitute for intraoral images. (Learn more on this topic at the author’s website, www.learndigital.net.)

To summarize, in order to go digital you’ll need to: update computers in your office as well as the operating system and PM software; select appropriate monitors for operatories; demand training from the vendor for both image aquisition and image processing tools; choose a solid-state detector to achieve the lowest dose possible; and consider purchasing a digital, multifunctional panoramic x-ray machine. Additionally, update your knowledge of current guidelines for appropriate use of x-rays, especially for children, including mandatory use of a thyroid collar (except where it will interfere with the examination, ie, panoramic and cone-beam imaging) and adoption of rectangular collimation.

About the Authors

Claudio M. Levato, DDS
Private Practice, Bloomingdale, Illinois

Allan G Farman, BDS, PhD, MBA, DSc
Independent Consultant in Maxillofacial Imaging Science
Chicago, Illinois

Dale A. Miles, BA, DDS, MS
Chief Executive Officer
Cone Beam Radiographic Services, LLC
Fountain Hills, Arizona
Vice President of Research
Interactive Diagnostic Imaging
Atlanta, Georgia
Private Practice
Fountain Hills, Arizona


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3. Farman AG, Levato CM, Gane D, Scarfe WC. In practice: how going digital will affect the dental office. J Am Dent Assoc. 2008;139 suppl:14S-19S.

4. Levato CM. Intraoral digital radiology: a safe, cost-efficient imaging solution. Compend Contin Educ Dent. 2011;32 spec no 4:48-50.

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