People think reading radiographs is easy. But its not just black and white…
There is a lot of gray area.
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Category: Radiography
Digital sensors and software. Advanced diagnostic images such as cone beam cat scans (CBCT) and 3D images. new radiation generators.
PRESS RELEASE From Carestream:
Carestream Dental has introduced the CS 2400P,* a portable generator that offers practices the powerful X-ray beam needed for exceptional diagnostic images yet is small enough to be handheld. It features an innovative battery-free recharging system that’s fast and convenient so it’s always at the ready to capture high-quality images.
Source: PRESS RELEASE: New Portable X-Ray Generator is Battery Free, Frees Up Wall Space
I have long been a huge fan of the Nomad hand held X-ray device. This new product from Carestream looks very similar. I do not know why any dentist buying an X-ray generator would even consider an old fashioned wall mounted unit.
New service Spotimplant to identify an implant based on a submitted x-ray.
AI-based | Spotimplant
How Does It Work?
1. Upload an x-ray image showing an unknown implant to identify
2. Our AI will analyze the image, and our implantology experts will review the results
3. You will receive your identification report shortly
Source: Dental Implant Identification Service | AI-based | Spotimplant
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X-Ray Sensor Security
A great tip from Henry Schein technology specialist Jason Ney.
Digital x-ray sensors are expensive and can be damaged or even lost. Extended warranty programs for most sensors cover technology failure but do not cover accidental damage. If you run over the sensor with a chair or damage the cord you are out of luck and on the hook for a whole new sensor.
After just a few years extended warranty coverage can cost as much as new sensor.
Jason’s advice is to avoid the extended coverage and simply add your sensor to your general business insurance. If it is damaged it will be covered and the premiums are much less than most warranties.
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XDR
Is it as good as film? Wrong question.
Is it diagnostic?
What makes a digital radiograph diagnostic? It is a combination of image and software. Dentists tend to focus on the sensor and the final image but it is the software that matters more – or at least as much – as the sensor when it comes to delivering a diagnostic image.
In this regard I have long been a fan of XDR Radiography.
Doug Yoon, the founder of XDR is a dentist, a scientist and one of the smartest people I know in dentistry. Doug recently reminded me of the XDR motto “Imaging Through Science”. What that means in practice is that the team at XDR is constantly looking to refine the digital x-ray process through scientific investigation based on diagnostic efficacy. Sadly some vendors concentrate on what looks good and what will sell rather than on what is the best diagnostic result. Instead of a lot of cool looking but useless enhancements XDR actually uses advanced image enhancement to improve diagnostics…what a concept.
Don’t get me wrong, XDR has one of the best sensors on the market as well as great software.
Are you up for some in the weeds, future focused, nerdy stuff? If so keep reading.
The opening question about film refers to our early attempts to diagnose dental disease from a digital image by looking at it, just we used to do with film. But do we really need to look at an image to diagnose? Do we even need an image? No, we do not.
When we diagnose an x-ray image, we are using our eyes combined with knowledge, training and experience to detect changes in tissue density. These density changes are indicated by how opaque the image is. We have learned that lack of opacity indicates loss of density which indicates pathology. We can see changes in the image because the pixels are displaying different shades of gray. Here is the part we tend to ignore. The computer knows the difference in each pixel even if it does not display it as an image.
Imaging software can be trained to distinguish patterns and changes in grayscale that are too subtle for the human eye to detect. Once the software has been trained to know what pathology looks like whether it is interproximal caries, periapical pathology or crestal bone loss the software can render a diagnosis without rendering an image. That is what machine learning and artificial intelligence is all about.
We are a ways away from total digital diagnosis and will certainly pass through a significant hybrid step where the software does a preliminary diagnosis and also renders an image for the human to look at. However, once you get past the film-based paradigm from the early days of Roentgen you can see that we do not need a picture we just need a data steam that can be used to detect tissue changes that indicate pathology.
Until we get there we will still need to use our eyes, knowledge, training and experience looking at the best image we can get to diagnose dental disease. XDR will help you do that.
Line Pairs per millimeter or LP/mm is a resolution measurement commonly used to evaluate digital radiography sensors. LP/mm is a measurement of spatial resolution, that is how small a space can you perceive. Spatial resolution is important if you want to see a very small item such as the tip of an endo file on a radiograph. It is not so important if you are looking for subtle changes in the density of enamel.
A line pair gauge like this one shows five line pairs (one dark and one light) converging together into a smaller and smaller space eventually reaching a maximum of 20 LP/mm. It is important to note the gauge only goes to 20. If a radiography vendor tells you that his or her sensor has a LP/mm of 23 or 26 one of two things is happening. They are mistaken or they are quoting a theoretical measurement based on pixel size.
Te problem with theoretical is that it is well… theoretical. The actual performance is always less, sometimes a lot less, that the theoretical upper limit. As a result the only reliable measurement of LP/mm is an actual test using the gauge and the highest possible score is > (greater than) 20.
In actual testing sensors range from as low as 8 to >20.
It is also important to note that in order for a human eye to actually see 20 or greater LP/mm the image must be magnified. Good spatial resolution is a result of both a high-quality sensor and well designed software that can display the image in an appropriate way. Some software enhancement tools such as sharpening may actually decrease LP/mm.
Some radiography vendors have made the claim that LP/mm is not an important measurement. In fact it is important for some things and not for others. It is important if you are trying to see the tip of a #8 file or a pattern of bone trabeculation. It is not important if you are trying to see incipient decay.
Thanks to Doug Yoon at XDR Radiography
From ScienceDirect: Following is the summary of this scientific article by E. Dianne Rekow, King’s College, London.
Digital innovations have unquestionably disrupted dentistry. With these innovations, patient experience has improved. More restoration options are available delivering longer lifetimes, and better esthetics. Fresh approaches are bringing greater efficiency and accuracy, capitalizing on the interest, capabilities, and skills of those involved. New ways for effective and efficient interprofessional and clinician-patient interactions have evolved. Data can be more efficiently mined for forensic and epidemiological uses. Students have fresh ways of learning. New, often unexpected, partnerships have formed bringing further disruption — and novel advantages.
Is digital dentistry disruptive? Absolutely. Is it destructive? Absolutely not!
Source: Digital dentistry: The new state of the art — Is it disruptive or destructive? – ScienceDirect
I have been saying the same thing for many years. It is nice to see some research backing me up.
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USB Sensor Saver
This looks like a great idea. I have not tried it or talked with dentists who have used it but the concept makes a lot of sense.
The leading cause of digital sensor failure is normal USB wear and tear? Issues like ‘half-images’, ‘grainy images’, ‘undetected exposure’, ‘random disconnects’, ‘hardware errors’, etc – are all likely symptoms of the same underlying issue; the added electrical resistance of a worn USB connector. The average USB connector is only optimal for approximately 300 – 500 re-connections. In a high volume practice, that’s less than 1 year.
Source: USB Sensor Saver
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The Captive Dentist
Imagine a world in which—if you owned a Volkswagen—you could only fill up at a Volkswagen gas station using Volkswagen gas. Ford gas won’t work. You can only drive in the Volkswagen lane and take the Volkswagen off ramp. If the Volkswagen off ramp is closed for repairs, you can’t take the Ford or Toyota off ramp. That whole scenario is ridiculous but it is basically what happens when we use closed proprietary dental systems.
Interoperability is the ability of different systems from different vendors to work together. The opposite is proprietary, where users are restricted to one vendor’s products.
Dental management systems with electronic records, digital radiographs and digital impression systems are all highly proprietary. That is the user can not transfer a patient record from one office another electronically. Radiographic sensors are limited to specific software and some vendors even restrict which transfer system a user can use to send and impression over the Internet.
When shopping for a digital product, tell the vendors that an open system is an important buying factor. Ask the sales person if you can transfer the digital impression to any lab of your choice or if you can load the impression into design software of your choice. In most cases, the answer will be no. Let the sales person—or, better yet, the sales managers and product managers—know that you won’t buy a closed system.
Vendors love closed systems that keep dentists captive. They will not change until the dentists buying the systems demand a change.
Download free educational materials, infographics and more to share the Digital Dentistry Difference story, and see the difference it makes for your patients and your business.
Source: Home – Carestream Dental
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DEXIS Smart Image
From Dentrix:
The much-awaited Dentrix® Smart Image connector for DEXIS is now available! This new imaging integration can mean unprecedented time-savings, clinical care enhancements, and revenue opportunities for Dentrix users.
Dentrix Smart Image expands your ability to provide quality care by connecting your clinical and financial process into one efficient workflow.
Source: DEXIS Smart Image | Dentrix
| If you use DEXIS with your Dentrix system, it’s time to take the next step in imaging. When you make the switch to Dentrix Smart Image, you keep the basic functionality you have known and loved in the workhorse DEXIS Integrator for Dentrix™. Plus, Smart Image delivers new automated workflows and processes that simplify your imaging process: |
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From Becker’s Review: If you read the article it doesn’t really amount to much. Supposedly no pathology was missed and no one was damaged by the failure to read the scans. If that is true, is there really any value to insisting that all CBCT scans be read by a trained radiologist?
At this time the pathologists and radiologists assert that all scans should be read by an expert and they make some good points as to why. However in my experience most scans are not being submitted for investigation by a specialist. Is that a breach of standard of care? or is it just lazy? Or is is actually OK if it makes no difference to the patients?
The best high tech solution will be for a trained AI to do a preliminary evaluation of all CBCTs and identify any that need additional evaluation.
Radiologists at Bethesda, Md.-based Walter Reed National Military Medical Center failed to read and diagnose nearly 2,000 dental scans, according to an internal investigation cited by The Wall Street Journal.
Source: Walter Reed failed to examine nearly 2K dental CT scans, investigation finds
Where should you spend your one million dollars of section 179 money before the end of the year?
Section 179 is the tax law provision that allows businesses to expense certain capital investments. For details regarding the law look here.
Complete or upgrade your technology infrastructure. If you still do not have computers in every treatment room linked to a server do that now. Every other high-tech system is dependent on a complete network. If you have a network but it is more than four years old, it needs upgrading. ($25,000 or less)
An alternative is to use XaaS. With this system the service company provides all the computers and networking and the dentist simply pays a monthly fee for the service. There are definite advantages to this however XaaS does not qualify for section 179.
Radiography. There is no excuse not to be exclusively using digital radiography in 2020. If you do not have a basic sensor system get one now. You only need one basic sensor linked to you practice management system. ($4,000)
If you have a sensor then consider a digital panoramic machine. You will be able to see and diagnose more effectively and it will pay for itself in less than a year. ($10,000)
If you are a surgeon or if you place implants then consider a Cone Beam CT. ($80,000)
An interesting alternative to x-rays for interproximal caries detection is the CariVu from Dexis.
Once these basics are taken care of you are ready to consider more advanced systems starting with digital impressions. You can start with an impression scanner only; you do not need to get a full CAD-CAM system with a mill. However, be sure you can add a mill in the future if you want. ($23,000)
Next look at getting a laser. Start with a soft tissue diode laser. You will be amazed at all you can do with one of these inexpensive lasers, starting with tissue troughing around preps. You will never need to pack cord again. ($1,800)
If you have everything on the list so far and are looking to take the next step, consider a hard tissue laser. My favorite is the Solea. They just introduced a new improved version. ($100,000)
As always you would be a fool to consider this tax or legal advice consult your CPA etc. etc. etc.
Cone-beam CT (CBCT) performed better than periapical radiography in detecting the apical delta in more than 100 premolars, but both modalities fell short compared with the gold standard of microcomputed tomography (micro-CT), t
Source: Study tests imaging modalities’ accuracy on root canal anatomy
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CBCT can Detect root fractures
Cone-beam computed tomography (CBCT) is useful in detecting vertical root fractures (VRF) in vivo even when the fracture line itself could not be visualized on CBCT, according to Russian researchers
Source: Endodontics — April 12, 2019
What makes all of the amazing things possible we see with CBCT is that second “C” it stands for “Computed”. The fact that we have a digital image and it is analyzed by a computer allows us to see, or more accurately distinguish things that we could never actually see with our naked, unaided human eyes.
For example a single radiograph pixel could be one of at least 256 shades of gray. Our unaided eye cannot distinguish any difference between say shade 124 and shade 125. However the computer can “see” a difference. The computer can then be taught (programmed) to to find pixel patterns that indicate a pathologic change (such as a root fracture).
We often get hug up on what we can see on a displayed radiographic image and compare that to film. However the actual value of a digital image is not how it compares to film but that it is not film. A digital image contains far more diagnostic data than film, we just need to use the computer to help us see what is there.
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Photos and Digital Charting
If you get a good set of intraoral digital photos and x-rays you can do much of the charting at your desk. You no longer need to be chairside with the assistant calling out findings while she scribbles things down on paper. This is especially true with existing restorations, broken teeth and other conditions. You can also make a treatment plan from the digital photos and x-rays.
If you have a good set of intraoral photos you could even use them as your existing record rather than trying to put it on the paper chart.
If you ever are challenged in court your photos of before after and even during treatment will be the best documentation you can ask for.
We should develop clinical protocols to include photos on every new patient just as we take radiographs on every patient.
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Dentrix Smart Image is Here
From Dentrix Magazine:
Smart Image makes it easy for you to access more patient information quickly through a seamless integration without searching through separate software for a history of patient images.So, what imaging software do you use? Sopro by Acteon? Romexis by Planmeca? Sidexis 4 by Dentsply Sirona? Chances are that you may even use a combination of these tools as you capture 2D and 3D images. The good news is that the opportunity now exists for any of these vendors to integrate. We already have working integrations with several vendors, and we will be building more of these connections over the coming months. Please check out our Smart Image webpage, www.dentrix.com/smartimage, to see the status of the connectors that are being built, and to learn more about Smart Image.
Source: Dentrix Smart Image is Here – Dentrix Magazine
Smart Image is NOT a new imaging software. It is a new bridge and integration tool that allows Dentrix users to bring images from various 3rd party image applications into Dentrix.
When you acquire diagnostic images, Smart Image automatically associates them with the correct CDT codes for accurate billing, and displays them in the patient chart. Now the patient’s 2D and 3D images can be accessed without leaving Dentrix.
One of the most powerful features of a digital record, a digital radiograph, a digital impression or for that matter any digital application is one which is so obvious that it is sometimes ignored. It is an advantage which people with limited experience with digital technology often do not appreciate. That is, just the simple fact that the item is… wait for it… digital.
To digitize anything, including an x-ray or an impression, means to turn the information into the electronic language that a computer can understand. Once that has been accomplished there are three things you can now do with that information; you can store, transmit and enhance the data using a computer and a computer network.
Storage means that the chart, the radiograph or any other digital item can be part of an electronic health record. Without digital diagnostics there is no way to create a paperless record.
Transmission means that the item can be stored in a server computer and viewed instantly at any computer in the office. However beyond that the image could also be viewed instantly by the specialist across town or by the insurance carrier in another state or by a consulting radiologist in another country.
Enhancement means that the dentist can use software to bring out features in the image, analyse the surgical site or design a crown. Enhancement is the most interesting digital advantage and also the advantage which is often overlooked.
A digital impression is to a traditional impression as a digital photograph is to film.
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Dentrix Smart Image
Dentrix G7 and Dentrix Smart Image are the first products launched by Henry Schein One, the company formed by Henry Schein and Internet Brands to deliver better integrated software solutions for dentists. Dentrix Smart Image allows practitioners to access 2D, 3D and CAD/CAM images from the Dentrix Chart, while linking images with CDT codes that are posted to both the ledger and the patients’ continuing care record automatically. This not only saves the dentists time, but ensures they receive payment for all the procedures performed.
