Digital radiography is here to stay, if only because if the ease if storage and movement toward digitization of patient records as a whole. There are still some problems with “proprietary” file formats, lack of a generalized consistent radiographic standard and image quality vs. film. Clinicians investing in this technology must realize that initial costs can be very high and that recouping the costs of the system may take several years. Additional work may also be involved in scanning older conventional films into digital records with a flatbed or slide scanner. This extra labor must be factored into the equation. The potential benefits of digital image integration are numerous. Once records are digitized, correspondence that includes intraoral images (both radiographic and photographic) can be sent via E-mail. This has potential for better communication with patients, referrals and insurers. While the “on-line, real-time” interaction may seem far off, the day is rapidly approaching when remote diagnosis, consults and treatment planning will become a reality.
Factors to Consider when Contemplating Purchase of Digital Radiography Equipment
1. Have you added the costs of placing a digital network ( e.g./ Windows NT Server) in your office ? Not just the cost of the Digital X Ray system. I.e./ costs of running cable, ensuring adequate ventilation for PCs. Ergonomics of monitor and keyboard/mouse placement? Who will actually enter the data/ take the images? You ? Your assistant? This is crucial for in operatory keyboard placement.
2. Does your practice management software allow for seamless integration of the digital images ? Not “open two different programs at a time” ? This is important to ensure smooth work flow, to prevent mis-filing of images and to generate accurate reports.
3. Do you have a printer that prints at a resolution high enough to reproduce x rays with good detail ?( 600 DPI minimum)
4. If you have an Intraoral Camera, will the pictures that you now have be able to be captured and stored in the same image database along with the X ray images ? Will they need to be converted ? Who does this and how much will it cost ? Is a Colour printer needed? What is the cost per print?
5. How many sensors will you need ? If you run a large multi-chair practice, you may find it very inconvenient to be constantly moving one sensor long distances from room to room. Sensors (especially size #2) are expensive ~ $5500-8000 CDN each approx. (Costs !!)
6. What kind of support does the manufacturer provide ? Is the representative local? Will they guarantee to provide you with sensors by overnight delivery if yours requires repair? What is the track record of the device and the supplier ? How many previous installations have they made? Will they provide you with the names and phone numbers of a minimum of six satisfied customers in your geographic area who are using it for six months successfully?
7. Does your Digital Radiography company provide an “Upgrade” service to replace your sensor when it becomes obsolete? (It doesn’t take long!) How much extra/yr. is this service? How much does the yearly service/support contract cost? What does it include? Is there a fee for onsite visits when you have problems that occur with MS Windows? ( These may not be directly related to the Digital X Ray product so they may not be covered by your service contract!!)
8. What kind of software comes with the sensor ? What kind of reports does it generate ? Ease of use with MS Word? Does it have one click E-mail and file transfer capability ? Can you search the database?
9. For the "True digitally Based - Paperless Office" it is often necessary to redesign the whole traditional dental office layout. It is MUCH more difficult to retrofit these systems to an existing office. For those considering a complete remodel or who are opening a new office, this may be feasible. But for most clinicians, the cost of gutting their existing office to accommodate all the necessary hardware/software/ and operatory ergonomics may be prohibitive. Digital radiography can be used in these offices but less effectively than those offices that have been optimized for digital integration.
Types of Digital Radiography Systems
Wired Systems– Schick, Dexis, Trophy, Regam, DMDx and many others. These systems offer CMOS or CCD based sensors that are attached to PCs via wires. Thickness, size and shape of sensors varies with design. The advantage of the wired sensor is the ability to instantaneously acquire an image. Image quality also varies with the manufacturer and is related to the number of “pixels” on each sensor. Wired systems require you to plug the sensor directly into the computer when you move them. Although there are constant improvements in sensor design, these sensors have not consistently reached the quality of image comparable to film, especially in the posterior maxilla . This is counterbalanced by the 60-80% reduction in radiation exposure, tools that can adjust contrast and brightness and convenience of the digital data format. Wired systems are by far the most popular and represent the quickest, most efficient method of obtaining a periapical or bite wing image. Wired systems are particularly suited to endodontic applications because of the speed of image and ability to accurately obtain a length measurement. Dexis has been cited by several authorities as having the best image but more recently some clinicians have begun to prefer Seimens Sirona system. Schick has a high number of installs but has had a spotty record regarding reliability of sensors and product support. Patterson has only recently taken over the Schick product, here in Canada.
PSP (Photostimulable Phosphor) Based Systems: Soredex Digora, Dentsply Denoptix The phosphor coated “plates” that are used capture the images resemble film in appearance. Pre-wrapped plates are exposed and scanned via laser scanner. Exposures are similar to CCD based units. Digora plates are scanned individually and FMS can take longer to process than conventional film. Denoptix can scan a full mouth series or panoramic images in one pass via a rotating drum-type mechanism. Images are not instantaneous (90 to 180 sec.) A central processing area is needed where the plates can be loaded into the reader. Images are good but software integration with many practice management systems has been slow (Digora), but better with Denoptix. PSP systems have the potential for surpassing film in quality because unlike pixel based systems images are limited only by the phosphor grain size. High initial costs of purchase and time needed to process images have slowed sales. The Denoptix system can also be used with panoramics. Denoptix is also US based Vs the Finnish Digora.
Should You Buy Now?
The decision of when to purchase Digital radiography is dependent on many factors, many unique to the individual practice. The most significant factor (costs) follows the rules of other digital technologies. For example: Five or ten years ago, $3,000 would buy you a high end PC with close to state of the art processing. Not the fastest, but very good for that time. The same $3000 will buy you the equivalent technology of the day, today. Prices for state of the art computers have not come down. They have remained relatively fixed. Should you want an older processor or slower machine, these can be had at a discount, but the technology generally is considered "old". X ray sensor costs are similar. Size #2 (BW) wired sensors will remain the same in price because the technology is constantly being upgraded. If you expect to "wait" until prices drop, just like PCs, you will find yourself chasing the technology with similar prices at all times. There are no bargains to be had unless you wish to buy "older" versions of this technology. Be careful to buy from reputable dealers, support is very important.
Where Do I Start?
If you are just getting started with computerization of your office, or are unfamiliar with Networking computers, then I suggest that you wait to purchase digital x ray equipment. You need to make sure that all your front desk, accounting and patient management software is up and running smoothly before you consider this purchase. Having the benefit of many years of experience, I suggest the following timetable for smaller offices interested in pursuing digital imaging technology.
1. Purchase stand alone single PC for front desk. Purchase the software first and then the hardware. (The software supplier can often get you a good deal and can install it all for you. This offer s "one stop" solution for you when you need support (and you definitely will !)
2. Consider buying a second PC for your desk that is connected to the front desk PC. This will allow you to access patient files from your desk and work with accounting, patient management and word processing applications. An Internet connection is also very beneficial and can often be bundled with your office cable-TV hookup. It will allow you to use E-mail and communicate with referrals and patients.
3. Purchase an intraoral camera and install it in your hygiene room. It is the best investment you can make, if your staff is trained to use it properly! Clinicians who already have networks in place should consider integrating these analog intraoral cameras to digital format. (All you need is an inexpensive "capture card" that allows you to store the images on a hard drive, in digital rather than analog format. In that way, the pictures become part of the patients electronic record and are not merely printed by a video printer.
4. Once a Network, dedicated server and operatory PC workstations have been installed and are working without a problem for 6 months, you are ready to consider digital radiography.
5. Realize that the learning curve for this technology can be very steep. Those of us who have bought computers as "time saving" devices that generate "less paper" have found that we often spend MORE time at our desks than we did before. The work can be more interesting and satisfying but this technology often results in more work, not less, for you.
One last thought:
If you are an older clinician and feel that computerization/digitization of your practice is “not necessary” or “ too expensive” you need to consider this: You can be certain of one thing, the sooner you computerize, the more your practice will be worth when you sell it. Why? Because digital records allow the potential purchaser to get an exact snapshot of every aspect of your practice. The days where practices were sold on the basis of “numbers of charts” or “goodwill” are definitely over. The young dentist looking to purchase a practice wants patient statistics (average age, average distance from practice, percentage of insured patients, percentage of insured benefits used, production breakdowns etc.) before he buys. If you can’t produce these numbers, you are never going to get the sale price you expect. The sooner you start to enter this data (and it does take time!), the better your chances of a satisfactory sale price. Data= $$$. Data is the currency of the future.