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The Status of Digital Radiography in Endodontic Practice:
Are we there yet? 

The Perspective of One Clinician Who Very Much Wishes to incorporate Digital Radiography into his Practice…but on his own terms.

Digital Radiography. Say those words and most clinicians express immediate interest but are rightfully concerned with cost/benefit ratio. Dental Products Review has frequently published statistics that say that while Dentist's interest levels are high - costs remain a concern. Lets examine what is involved, financially, if we wish to move to this technology.

Cost Considerations

Besides purchasing the sensors and imaging boards, it also means that a dedicated server (with backup) and workstations must be installed in the office. In some cases, the entire office Practice management software/hardware setup must be changed.  This occurs when older software is unable to seamlessly incorporate images into its database. The ultimate nightmare is an office with software packages (Practice Management/Patient Database, Intra-Oral imaging and X Ray imaging) that are unable to "talk" to each other.  Spending $75-100,000 CDN to equip a 3 operatory clinic in this manner means that a LOT of images (several years' worth) must be taken to even begin to recoup the costs (vs. film) of the initial investment.  The unfortunate part of this evolving technology is that by the time your system has been paid for, its sensor technology and imaging capabilities will no doubt be obsolete. Some manufacturers are now offering a "no-obsolescence" option that provides for hardware and software upgrades as the technology changes. This is available (at a premium…of course).

Who Will Pay for this Technology?

The second problem is whether to charge a "surcharge" for the use of digital radiography. This is the prevailing attitude of many of the American clinicians using the technology. Just raise the fee.

Explain the benefits of digital radiography to patients to justify the fee increase.

70 % of Canada's dental patient base is covered by private dental insurance but it is likely that this surcharge will not be covered by insurance plans. Patients who are accustomed to having insurance reimburse them for 100 % of Diagnostic costs will no doubt complain about this surcharge. If you have made the decision to accept direct assignment of insurance benefits, you will find it difficult or impractical to collect the surcharge if the balance is only a few dollars. While these few dollars may seem small, multiplied by the number of films taken, they DO add up. When I think about the time that would be required to "explain" why there is additional $5 or $10 charge to the patient, it hardly seems worth the effort.  In other words, in most cases surcharges are impractical.

Ergonomics – Do these systems save as much time as they claim?

When considering the economic ergonomics of digital radiography, sensor based manufacturers are quick to point out the "time saving" features of CCD based radiography. Is this really the case?  What they fail to mention is that in comparison to regular film, it can take more time to place these sensors in the patient's mouth (especially in the presence of rubber dam/clamps/files etc.). This occurs because of:

  • the need to enter the patient's information in the computer database (tooth #, etc)
  • the need for bulky customized sensor holders (standard hemostats cannot be used on CCD sensors)
  • plugging/unplugging sensors in the case of a multi-op/single sensor installation
  • the need to place barriers on the sensors for each patient or changing them when alternating between patients
  • sensor thickness, inflexibility and rigidity of corners
  • Labor costs in preparing hard copy reports.

This includes opening the electronic patient record, pasting images and printing the document. If full color intra-oral camera images are also part of the record, a good quality printer capable of continuous tones (Dye sublimation) coated images is absolutely mandatory. Inkjet or lasers printing at 600 dpi can sometimes used but are not archival quality. B&W thermals are best left for disposable images because of fading. Printing costs can average $1 per 4x6 sheet, and $3 or more for full coverage 8x10s for best photo quality images.

Those who use smaller or rounded sensors may also have more retakes. Some sensors are also not comfortable or usable in certain areas of the mandible and maxilla. You may occasionally have to return to film and then have the extra step of scanning these films into the electronic record.  All these factors have to be considered when computing "time savings", though digital radiography sellers rarely mention them.

PSP Based Systems
Phosphor based plate technology (Digora and Denoptix for example) offer a plate-based system that resembles film in size and physical appearance. My staff and I had a very favorable initial response to the Digora (Soredex Finndent) when used in my office. Staff felt that the plates handled just like film. No special holders were required.  We could tolerate the 60-90 second processing time because as an Endodontic office, we were usually taking films one or two at a time. This processing time was similar to that of hand developing films with high speed developing solutions. (We mix our own developer from inexpensive raw chemicals. Contact Dr. Kaufmann for the formula.) Asepsis was easy with the "film-like" plate wrappers. The images were very good.

But problems immediately arose with the location of the unit.  The unit had to be placed in one operatory because of the current office and computer layout. This meant that a staff person working in an adjacent operatory often had to exit the operatory (I have three ops with PCs in each) and access the keyboard in an adjacent operatory where the Digora processing unit was located.  This was necessary to ensure that the film was placed in the proper patient file. The unit decides where the scanned plate images are filed by sending the scanned image to the active open file. This arrangement presented problems with patient confidentiality, asepsis and possible misfiling of images.  A central "Digora processing area" would be preferred but still offers the possibility of misfiling films if more than one patient is being treated at a time. (This can be corrected by exporting the image to the proper chart but it does offer greater room for error.) Physical alteration of an office may be required to accommodate the processor and/or installation of an NT Server for multiple operatories/stations. Again, suppliers rarely mention these costs.

Digora's initial software support was also abysmal.  I met with Soredex USA representative Juha Korhonnen at ADA/FDI in Orlando Fla. in 1997 and corresponded with him for several years. I suggested that one of their main competitors (the CCD based company Schick-CDR) was making significant impact in sales because of their decision to market heavily to Endodontists. Schick understood the Endodontists need for good radiography and generation of high quality post-operative endodontic reports.  Schick's reports (in full photo quality color with intraoral video captures using a Fargo Fotofun Dye Sublimation printer) were being sent to General practitioners throughout the US on a daily basis. General Practitioners understood how particular Endodontists are about films and radiographic images.  If Endodontists endorsed Schick's product, then surely it was worth a look by the General Dentist. This was very smart marketing derived from the heavy influence of Schick's Endodontic investors. Furthermore, Schick was quick to provide bridges, limited integration and hot button access to American software manufacturers. Soon it became common to see practice management software that advertised that it "Supports Schick CDR".

In my correspondence to Soredex, I explained that the problems with Digora centered on these areas:

(1) Inability to process multiple plates
(2) Lack of ability to accept and process color intraoral and video images in their software.
(3) Extremely poor report formats and hard copy output
(4) Minimal interest integrating with the most popular US software.

 

Problem (1) has been addressed with Soredex's recent introduction of a multiple plate loading system that now accommodates up to 20 plates. (However, the processing unit still must process the images one plate at a time @ approximately 60 seconds per plate.)  

Processing a full mouth survey can be slower than most conventional film processors.

Problem (2) has been addressed with the creation of Digora software V.2, that now allows import and storage of intra-oral video captured images. Their most recent version appears to comply with the "Dicom" radiography standard that has yet to be universally accepted by Dental Radiography manufacturers.

Problem (3) remains unsolved. Report format templates had no ability to seamlessly import critical referral dentist data from common practice management software. This means duplicate entry of the patient name; referral name etc. must be performed, which is inefficient. Soredex could learn a lot from the Schick and Dexis formatted reports.  This is THE MAIN REASON why I elected not to pursue this product.

Problem (4) is a question mark. It appears that Soredex thinks the Endodontist market is not a viable direction to explore. They have had little or no representation at the last several AAE annual meetings. By contrast, Schick has consistently been one of the most visible hi-tech exhibitors at recent AAE meetings as their market penetration figures show. After many calls and letters asking Soredex to interface with PBS Endo, Tiger Scan and other programs, their attitude has been less than helpful. Recommended telephone calls were never made and it seems that Soredex has minimal interest in promoting Digora to Dentists in the US, much less to Endodontists. Soredex Finndent is a big supplier of Medical imaging equipment and it appears that they are more interested in dealing with Cephalometric/Panoramic sales.

Denoptix (Dentsply) is a relatively new product that addresses many of the shortcomings of the Digora unit. It offers the ability to use multiple PSP plates of different sizes (up to a full panoramic size film) and scans them with a large rotating drum mechanism. Unlike the Digora unit, Denoptix allows a clinician to load a full mouth survey (multiple films, sizes and panoramics) into its scanner and have all films scanned and displayed within a few minutes. It also has been more helpful with integration into practice and image management software. If I was routinely performing full mouth surveys AND panoramic films, I would give this serious consideration.



Support

Support issues are always critical with new technology. Most recently, the financial health of Schick has recently come into question.  One of Schick's Canadian distributors is quoted as having reliability problems with sensors, so much so that they must keep a large inventory on hand to supply clinicians that require immediate sensor replacement.  They are currently recommending the Dexis system because of the quality of the Dexis components. Recent publicity surrounding accounting irregularities in Schick have led some to believe that while sales may be high and market share considerable, the financial health of the company has been questionable. Schick has also noticeably downscaled its presence at most recent Dental Conventions.  This may influence the decision to purchase, since a company's viability has a direct effect on support. Support is a big part of incorporating new technology into a dental practice. Recognizing that their service component needed improving, Schick has partnered with Patterson Dental. It remains to be seen whether Patterson reps have the necessary knowledge to install, maintain and troubleshoot this new brand of technology.

Most recently, a company called DMD has entered the market with DMDx, the thinnest sensor available (a wired sensor just over 3mm thick). Since the product was only introduced in Nov./Dec. 99, a thorough evaluation has not been performed at this time.  In typical fashion, the salesperson that demonstrated the DMDx product found that it did not work properly with his Toshiba notebook computer. We were unable to create any images. Vaporware strikes again.

I also recently attended a recent lecture by Dr. Gary Carr www.perfendo.org who compared images generated by both the DMDx sensor and Dexis. The Dexis images were obviously superior. Dexis also is supported PBS Endo (my current practice management/patient database) and has an excellent report generator that is fully configurable and integrated with patient databases.  After examining all the possible candidates, I elected to go with Dexis in May of 2000.

Dexis – Initial Impressions

Aside from a few network-related problems, the Dexis system itself has performed fairly well over the past months. There is no question that even with the advantage of digital enhancement tools (ability to adjust brightness and contrast) the images do not match film in quality. It is often difficult or impossible to determine whether files of sizes #06 or #08 are at the radiographic terminus.  Fortunately, when combined with an accurate Electronic Apex Locator (EAL), excellent results can be obtained. {See Proper Apex Location Technique for tips on how to get the most out of your EAL} When performing endodontics, these technologies must be used together to accurately determine the apical foramen position. Working lengths are best visualized with a minimum size #15 file.

Summary

Endodontics represents one of the easiest and best applications for Digital Radiography.  The challenge of incorporating digital imaging into Endodontic practice has several problems that have yet to be addressed:

(1) High initial costs,

Those waiting for the price of this technology to drop will find a situation similar to that of buying a PC computer i.e./ a reasonably state of the art computer (latest processor) cost $3000 ten years ago and will likely cost the same amount 10 years from now. As technology improves, the cost point will remain the same.  DO NOT expect digital x-ray prices to drop appreciably very soon. There is no advantage in "waiting" unless you wish to purchase outdated technology.

(2) Reliable, consistent image quality and support in the case of CCD based systems

The proliferation of companies supporting this technology means that like the intra-oral camera shake-up of the 90's, many may not be around for long.  This technology requires intensive, expensive, reliable and knowledgeable support from dealers. That means that Dental sales reps now have to be very computer literate, something that very few can claim. Familiarity with Dental supplies will not be enough. Clinicians practicing in rural locations or away from major urban centers may find it difficult to get prompt service. Frustration levels can be very high. This can be a real problem when your office has gone "filmless". Many clinical experts say that PSP technology offers the best promise for image quality, possibly surpassing that of film.

(3) Ability to seamlessly integrate into practice management software, report generators and image databases.

The proliferation of Dental software packages (including Specialist software) and lack of standardization of data entry means that Dentistry still does not have a universally accepted format that allows software to seamlessly to talk to each other reliably.  There are always bugs, omissions and factors that prevent importation and exportation of data. Removing a few commas, spaces or entering a few fields may not seem like much, but it becomes tedious when it must be done with thousands of patients. When you wish to import data wholesale into your new software, proprietary databases or image formats can be expensive to convert or impractical to use.

Endodontists have been at the forefront of incorporating Digital radiography in their practices. They recognize the benefits of digitized radiographic and image capture, manipulation and storage. Since they are only taking a few exposures at a time (per tooth) they have the easiest time incorporating this technology into every day practice (assuming that their offices are properly equipped with computer networks and management software that incorporates these images). Digital radiography will eventually become the standard, simply because dental records in general are moving toward digital media. The challenge for the average clinician is incorporating the technology into their practices and making the transition without incurring unreasonable costs or being left with unsupported technology in the event of bankruptcy of the supplier or remote practice location.