The Current State of Digital Radiography
John C. Comisi, DDS, MAGD | Allan G. Farman, BDS, PhD, MBA, DSc | Andrea Robbins Margeas, DDS
The Roundtable is a forum for debate on key topics, trends, and techniques in dentistry. For each edition, a panel of experts will take on a subject to help expand your knowledge and boost your practice. About 10 years ago, the penetration of US dentists owning digital radiography was about 10% to 15%. Today, recent indications are that the market is penetrated by 60%. In this edition of the Roundtable, our panel discusses the current state of digital radiography. To view a video of the entire conversation about digital radiography, click here.
About Our Panel
John C. Comisi, DDS, MAGD, is a clinical instructor at the University of Rochester School of Medicine and Dentistry in Ithaca, New York. He lectures nationally and internationally and is a spokesperson for the Academy of General Dentistry and a prolific published writer. Dr. Comisi is a graduate of Northwestern University Dental School.
Allan G. Farman, BDS, PhD, MBA, DSc, is an oral and maxillofacial radiologist and an independent consultant in maxillofacial imaging science. He has PhDs in both oral pathology and oral maxillofacial radiology, along with a higher education degree and an MBA. He is part of the ISO DICOM Standards Committee and ADA Code’s Maintenance Committee for the American Dental Association. He has published over 400 peer-reviewed articles and books.
Andrea Robbins Margeas, DDS, is in private practice with the Michigan Dental Group in Port Huron, Michigan. She is completing the Kois program and is an active member in the Seattle Study Club in Port Huron, as well as the Michigan Dental Association, American Dental Association, and the Academy of General Dentistry. She earned her degrees from the University of Michigan and Detroit Mercy School of Dentistry.
Inside Dentistry (ID): When do you think digital radiography will be the standard and when did you incorporate it into your practice?
Dr. John C. Comisi: We incorporated digital radiography into our office probably 15 or more years ago. At that time, we saw the need to move from film to a digital rendering of our images. The technology and the amount of radiation being used for a radiographic image with digital made a lot of sense too since it was reduced significantly. We used Lightyear Technology at the time and it was relatively inexpensive considering the other available technologies. We transferred our images over from the Lightyear system to DEXIS about 3 to 5 years ago, and that was a marvelous change because it really made everything even easier, and its integration into our office management system has really been a nice integration as well.
The timetable for full acceptance depends on the practice. It depends upon their perceived need or, even more interestingly, the demand, the requirement, or the recommendation from their patients. I live in a community that is very concerned with environmental aspects. They want to preserve the environment and are very concerned about all kinds of agents that could cause harm. Moving to a digital format and reducing the radiation needed and exposure to our patients was a very important move forward in my mind.
Dr. Andrea Robbins Margeas: In terms of the timeframe, I am estimating approximately 5 to 10 years, 5 years being the newer dentists. Obviously, they are going to be more excited to bring this technology forward and they will have had recent exposure. It will be a little more difficult for the dentists that have been in practice and concerned with cost and multiple factors. I had an opportunity 11 years ago to start my own practice and I did research, spent many evenings looking at the pros and cons, and it really was a no-brainer after looking at that. I initially chose indirect digital imaging with the photostimulable phosphor (PSP) plate system, DIGORA™ Optime, which is similar to analog film, comfortable for my patients, and reasonably priced. Then, I was introduced to the DEXIS sensor at a meeting. I was very impressed with their technology and brought it back to my team and they were ready; they wanted me to try it.
Dr. Allan G. Farman: I have been using digital radiology from the late 1970s for computed tomography in hospital settings. For dentistry I started using digital radiology clinically as soon as it received FDA clearance in 2000. Many dental schools are already 100% digital for all aspects of radiology and newer graduates are unlikely to use anything else. Lack of adoption is not a question of contrast or resolution as analog and digital are essentially equal. CMOS and photostimulable phosphor detectors have wide recording latitudes, so an excellent image can indeed be achieved at low doses, but is also possible with more than a magnitude of overexposure. The practitioner needs to select low exposure settings appropriately, so that they still provide suitable diagnostic images. We have just heard that digital can save radiation, but it also can increase radiation if it is not used appropriately. Some older dentists are adverse to change. When clinicians perceive the digital learning curve is not worth going through and startup costs will not be returned due to the short time to retirement, such dentists are likely to resist joining the digital revolution.
ID: What are some of the major advantages of going digital?
Farman: Digital solid state detectors produce essentially instant images so that the quality of each image can be assessed on the fly. With analog film, a series is processed together and there is a gap of several minutes between exposure and seeing the resulting images. This means that trainers and assistants get immediate feedback so education is facilitated. There is no need for a chemical processor, no arriving early to turn on and warm up the processor, and no need for regular cleaning of the chemical processor. There are no technical errors from processing procedures. There is no need for daylight loaders or a darkroom. There is no need to purchase processing chemistry or paying to have that used chemistry taken away. There is no silver contamination of liquid waste from the few practices where used chemistries are flushed down the drain. There is no need to buy a film that has one-time use only. With simplified infection control using digital intraoral sensors, we just need to put a plastic package over the sensor and to disinfect the sensor between patients. One can actually go to a paperless office where the images are associated with the patient through practice management software. There is easy retrieval of the images, no view box requirement, instant feedback on sensor placement correctness and diagnostic image quality, and no distortion due to film flexibility and bending. Total digital remote backup of all patient data has become possible, making a loss from an earthquake, mudslide, or fire fixable. Equipment can be easily replaced in the dental office, but the data is the real issue for any practice. There is ease of secured communication for insurance prior approval or specialist opinions. You have the ability to process and measure. You can zoom in on an optimized image on a large computer screen to show the patient rather than trying to explain features on the passport photo-sized piece of plastic. Disadvantages are software updates and equipment insurance, maintenance fees, and operating system update concerns. By far, the positives outweigh the negatives.
Made possible by generous support from DEXIS.
Margeas: That was a very comprehensive list. In our office, the bottom line is better efficiency, and the patients are excited and we are excited about the technology. We can show them an x-ray and be able to enlarge it and change the contrast, move the mouse, and show them areas of concern. Digital technology has allowed for better communication with specialists, enhanced patient education, and increased productivity.
Comisi: The bottom line is the effectiveness of communication when you bring a digital image up and you can show the patient rather than putting up that little 1-inch square that they could never see. It becomes more real to them because they can visualize and you can explain to them in a much more effective manner what is going on. Digital communication via sending to the specialist and communicating with another clinician is invaluable, not to mention the insurance companies that we send information to as well.
ID: What could you say to make a compelling case to move forward for those who have not adopted digital radiography?
Comisi: If you are a senior doctor who is getting within 5 to 10 years of selling your practice or retiring, you certainly want to have a digitalization mechanism in place. You want to have some kind of digital radiography and digital panorex available if not using CBCT. This makes your practice more valuable. It makes your assessment of your patients’ needs more effective, as well as your communication to the patient and to other referring doctors and insurance agencies. If you are not digitized at this point in time, I think you really ought to consider it.
Farman: I cannot imagine a world without digital being center stage. We are now getting voxels and pixels in everyday life. I think in the future it will become cost-ineffective to manufacture and sell analog radiographic film to dentists, and that it will cease to be readily available, just as has been the case for regular photography. It is going to happen because there just will not be availability of anything other than digital systems.
Margeas: I agree. I would encourage dentists, young and old, starting new practices—the time is absolutely right now to take on the challenge and become digitized. I do not see many negatives. I only see positives in terms of enjoying your practice, giving the absolute best to your patients, and having an enjoyable time in doing dentistry.
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