Hardware Radiography

Clinical Computer Monitors

One of the smartest guys I know is Doug Yoon. Doug is a dentist but more importantly he is a digital image scientist and the founder of XDR digital radiology. I asked Doug to give me some advice on the best clinical monitors for digital radiography. Here is what he had to say.

Even the lowest end monitor has sufficient pixel resolution for most digital radiographs.  The two most important parameters that manufacturers publish are brightness and contrast ratio.

We recommend a brightness of at least 350-400 candela per. sq meter. (cd/m2) and a static contrast ratio of at least 1000:1.

Note: Dynamic contrast ratio is a misleading parameter because it compares contrast between frames which can generate amazing million to one ratios. This is not relevant for viewing radiographs because these are ‘static’ non-changing images.

However the best test is to view a few radiographs on some candidate monitors  This is because intangible, un-reported parameters like SNR and precision of voltage control over each pixel can greatly influence image quality – especially when it comes to discrimination of subtle difference in gray scale.  Compromising in these parameters can allow manufacturers to cut corners in design and manufacturing costs, yet they can still tout ‘good’ specs for brightness and contrast ratio.


Guide to Digital Radiography

What is your excuse?

Digital Radiography is no longer new; it has been on the market for close to thirty years. If you are not using it you probably have a convincing personal excuse. On the other hand you could compare film x-ray users to a dentist still using a belt driven handpiece in 1995, thirty years after the air turbine was invented.

There is no longer any excuse. Make 2016 the year you lower your patient’s exposure to radiation, improve diagnostic efficiency and reduce the cost of taking radiographs. If you are still wondering what to get and are concerned about costs check out my comprehensive technology guide, “Digital Radiography”

The “Digital Radiography” guide exposes nine myths about digital radiography and it will answer the basic question…Why bother? It then provides step by step help choosing and then setting up digital x-rays.

You will learn about; the five part imaging chain, the sensor wars, image enhancement and much more. And what will come as a complete shock to most dentists… there is even a budget and financial analysis that shows how digital radiography is actually cheaper than film.

“Digital Radiography” will answer all your questions, provide a plan and show you how to save money… all delivered in a fun and easy to understand style.


Digital Radiography.

Internet Management Radiography

Dexis for Dentrix Ascend

ascendNew at the Chicago Midwinter:

Dentrix Ascend the cloud computing practice management system from Henry Schein now has a much needed new feature. Cloud based radiography.

Cloud based digital radiography has been a challenge. The speed of data transfer has limited the effectiveness of cloud based systems such that most dentists used a locally installed radiography system. This worked but negated all the built in advantages of having a cloud system in the first place.

Working with the radiography experts at Dexis the Ascend programmers have developed a patented algorithm that compresses the image – without loss of diagnostic data – that makes the speed of transfer so fast it appears to be happening locally. Very impressive.

The new program is built to integrate seamlessly with Dentrix Ascend. As with the core Ascend product the new radiography system is designed from the ground up to take advantage of digital technology. That is to say the workflow is not based on old paper and film practices but is based on how we can be most efficient using digital systems.

For example the user chooses the type of image(s) being taken prior to exposure. Once taken the image is automatically linked to the tooth in the patient chart and the ledger is updated to show the procedure and the fee.

This new feature makes cloud computing a much more attractive alternative to dentists looking for a practice management solution.

There is a second cloud based system Curve Dental that has cloud radiography.

Just for Fun Management Radiography

Harriet the Harried Dental Assistant

Harriott the HarriedIn case you missed it here is a link to a classic article from last year in Dentalcompare. It is intended to be fun and funny however you may recognize some things that actually happen in your office. If you are still waiting to convert to digital radiographs read this.

Back with the patient Harriet is ready to try again. Mr. Grumple has been here almost an hour, he is still in pain and now he is clearly ticked off. Judy the front desk fool person is standing in the hall frantically gesturing toward all the people in the waiting room and pointing at her watch. Dr. Paperman steams in, sees what is going on and asks, “Where is the x-ray?”

Harriet bursts into tears.

via Harriet the Harried Dental Assistant |

More Help:



dicomlogocrDICOM stands for Digital Image Communication in Medicine. It is an international standard for digital radiography that covers everything from hospital CAT Scans to dental periapicals. It is the DICOM standard that assures the reliable transfer of images from one system to another.

The DICOM standard also calls for the transfer of essential data along with the image. This includes the patient name, the date the image was acquired, the tooth number, the orientation and more. By arranging these critical data elements in a standard format they can now be transferred along with the image in a reliable manner.

To understand the concept, relate it to our old photographic system. A radiograph is just the image. Data elements in the form of the patient’s name, the date and tooth numbers are attached to the image by writing them on a mount or an envelope that holds the x-ray. As long as the mount and the image stay together we know about the film. However sometimes they are separated. Virtually every dental office has found an orphaned x-ray stuck behind the file cabinet at some time. With the data elements removed, in other words with the mount missing there is no way to ever determine whose x-ray it is and when it was taken. DICOM standards are the equivalent of permanently attaching the x-ray mount, and all the data it contains, to a digital image.

DICOM enhances interoperability. That is the ability of users to use different manufacturers systems with each other. The opposite of interoperability is proprietary.

Manufacturers like proprietary systems. Consumers prefer interoperability. Experience has shown that vendors will attempt to maintain control unless consumers demand interoperability.

Interoperability protects the dentist’s investment. If your brand leaves the market or another much better option comes along you can replace components as needed with other brands. The addition of DICOM to a digital radiography system does not make it more complex to the user. All the DICOM functions are invisible to the user; it does not require any additional steps to use. In fact the number of steps will be reduced when transferring or importing images as the user will not have to type in any patient data.

Radiography Software

Cloud Based Dental Imaging Software from Curve Dental

Curve Dental is a complete online practice management system. In order to be a complete system Curve offers image management, that is the storage and manipulation of digital images such as radiographs and photos.

Curve is a software company; they do not make or sell radiography sensors or cameras. That means their software needs to integrate with sensors and cameras that are already on the market. This is called interoperability, the ability of different systems from different vendors to work together. The opposite is proprietary. That is a system that does not work with others keeps users captive in a single system.

Following is a list of the sensors that work with the Curve system:

CurveImagingDigital X-ray Sensors

Carestream 6200

Cyber Medical Imaging XDR

Gendex GXS-700

Image Works (EVA)

Kodak/Carestream RVG 6100

Planmeca ProSensor USB

QuickRay Direct USB

Schick 33

Schick CDR with HS Remote

Schick Elite with Elite Remote or HS Remote

Schick WiFi

Suni Dr. Suni Plus with USB 2000 Remote

Suni SuniRay

Suni SuniRay2

Vatech EzSensor

Vatech EzSensor P

Video Dental Concept QuickRay

via Cloud Based Dental Imaging Software from Curve Dental.

This is an impressive list and includes some of my favorites like XDR and Carestream. However there is one major player who is missing.

When I asked the people at Curve why Dexis was not on their list the answer was simple, Dexis refused to cooperate.

Dentistry is infested with closed proprietary systems in management software, radiographs and digital impressions. A closed system is great for the vendors but bad for dentists and our patients. Dental vendors will not give up their proprietary systems until dentists demand it and refuse to buy closed systems.

On the other hand companies willing to open up to interoperability should be rewarded with our business.


CS Adapt Image Enhancement

RVG_6200Clinicians can optimize image contrast according to their diagnostic needs or visual preferences with the CS Adapt module—the new feature that lets practitioners establish their own default settings for personalized image processing. Users can choose from either 40 pre-set image enhancement filters or define up to four their own favorite settings, resulting in a customized comfort zone for every appointment.

via Digital Intraoral Sensors | RVG 6200 | Carestream Dental.

Most software tools sold to dentists to manipulate a digital radiograph have essentially no diagnostic value. For example colorizing the image looks cool but what turns red in one image has nothing to do with what might turn red in another and the red color is not related to any tissue or pathology. But it does look cool.

On the other hand one of the major advantages of digital over film is the ability to enhance the image. Different filters, different contrasts and different brightness can best show different tissues or pathology. There is an ideal setting for bone and another ideal setting for enamel. For the most part dentist have been left to blindly fiddle with the controls looking for the best view.

The Caresteam software comes with multiple pre-sets designed to optimize for a particular condition and also lets the user set their own pre-sets.

More Help.


Digital Radiography Savings

The number one reason dentists don’t have digital radiography is the cost. However if you ask most dentists they have no idea what they are paying now for x-rays.

According to the ADA the cost of a single film to the dentist is $1.10. That includes the film cost, about 40 cents as well as the cost of chemicals, processor, mounts etc.

The typical dentist takes 500 to 600 films per month. To get your number check your supply bill and see how many boxes of film you are using.

Do the math: 550 x $1.10 = $605 x 12 months = $7,260 per year in x-ray expenses.

A digital sensor will pay for itself in about a year just on the hard cost savings. If you include the time saved the ROI is even faster.


Sensors for Dummies

A corded sensor has three basic elements. First is a scintillator. When x-rays impact the scintillator it fluoresces, creating a very precise pattern of light.

Many, but not all, sensors have an optical fibre. It transmits the light from the scintillator screen to the chip and protects the chip from x-rays.

A solid state computer chip receives the light and converts it into a digital electronic signal. This is the same basic chip technology that a digital camera uses to convert light into a digital photo. There are two different types of chip in use; they are CCD (Charged Couple Device) and CMOS (Complimentary Metal Oxide Semiconductor).

These two chip types function differently but both produce good images of diagnostic quality.

More information about digital radiography in the dental office.

Dentalcompare Radiography

Taking X-rays Off the Wall

Nomad 2 hand held dental x-rayIn case you missed it. Here is a Dentalcompare article from March2013 about one of my favorite products – Nomad.

The NOMAD, a hand held x-ray unit from Aribex, looks like a big ray gun from an old sci-fi film. There is a body, a pistol grip and a cone or barrel that emits the x-rays. The operator aims the device and holds it steady while the radiograph is taken. The ability to stay in the room while you take the image and better yet hold the tube eliminates most of the problems we encounter when taking an x-ray…

Back in the day of wall mounted telephones, if you wanted to use the phone in the kitchen and in the living room you needed two phones each mounted and wired in place. And you had to pay for each phone including installation. It is the same with wall mounted x-ray units.

With a hand held unit you only need to buy one and there are no installation costs. You can use NOMAD in the hygiene room for re-call, in the overflow room for emergencies, and in the doctor’s room for root canals. One device takes the place of three or four wall mounted units, making it much more cost effective than the old system

via Emmott On Technology: Taking X-rays Off the Wall and by the Hand |

Handheld x-ray units eliminate most of the problems we have with drifting arms and squirmy patients. They are also much more economical than wall mounted units. BUT are they safe? The answer for the Nomad is yes. The unit has been extensively tested and proven to be safe. On the other hand not all hand held devices have passed the same tests as the Nomad.


Why Digital Radiography? More Than You Think

Most everyone is aware that a major advantage of digital x-rays is the speed of acquisition. Once the sensor is exposed the image is produced within seconds. This of course saves the time of going to the processor, opening the film packs waiting for the chemical processing then labeling and mounting the films. However there is another advantage to fast image acquisition which is rarely appreciated. The operator does not need to remove the sensor in order to see the image.

This creates a tremendous clinical advantage. For example if the doctor takes an x-ray and inadvertently misses the apex, he or she will see the error within seconds. The tube head or sensor (which has not moved) can be re-arranged as needed and another image taken immediately. In this way the operator can insure that hard to see structures can be captured for proper diagnosis.

With a film pack or a phosphor storage system the film or plate must leave the mouth and be processed. The operator will not see the image for several minutes. If there is an error the operator will need to re-position the tube and film with no physical reference point to return to to improve the image.

For more help with Digital Radiography look here and here.


Printing X-Rays

The secret to printing digital x-rays can be found in an old Nike ad. Just don’t do it!

There is rarely a good reason to make a physical hard copy. After all, one of the primary benefits is that the image is digital. Remember the benefits of digital; the data can be stored transmitted and enhanced with a computer. Once it is printed you lose all that.

You do not need to print it for the chart it is stored as an electronic record.

You do not need to print it for someone else; it is quite easy to transmit the digital image to anyone with a computer. It could be send via Internet or copied to removable media. The recipient does not need fancy dental radiography software; they can then view the image with basic image display software. On the other hand, if the recipient has radiography software they may import the image.

You do not need to print it for diagnosis; in fact diagnosis from a hard copy is extremely limited compared to an enhanced digital image.

If you insist on printing out an image you can do it with a standard inkjet or laser printer. You can use plain paper and the print will cost about a dime. The images will be adequate but not great. If for some mad irrational reason you want a high quality photo-like print you can use any of the photo printers available with high gloss photo quality paper. These prints will cost about a dollar.

Learn more about digital x-rays.


Interactive Imaging TV

A nice digital radiography  resource from Dale Miles (including CBCT):

Interactive Imaging TV.


The best way to print digital X-rays




Don’t do it.




More help choosing and using Digital Radiography

Diagnostics Radiography

i-Cat FLX

At the Chicago Midwinter:

One of the most exciting new products I saw introduced at the Chicago Midwinter was the i-Cat FLX. The most significant thing that makes it exciting is that the new system allows you to take a complete 3D image at a radiation dose that is lower than a typical 2D panoramic. That is so important let’s say it again:

3D image at a dose lower than a 2D pan!

Plus, and it is a big plus, the new control panel employs a simple easily understood visual system to guide anyone through he process of setting up and taking a great scan.

The third great feature is that the user can now choose from several different scan volumes from a full head as needed for orthodontists to a single arch. This allows user flexibility to provide needed diagnostic information and still reduce the exposure when possible. That is the essence of ALARA.

And it does all this faster than ever before. Both scan times and image processing times have been reduced.

Full Press Release below:

Diagnostics Radiography

Personalized CBCT Education

Another online reesource for Cone Beam CT (CBCT) training. From Doug Chenin of Anatomage.

Our hands-on courses can give you a solid foundation of clinically correct imaging principles that can be immediately incorporated into your practice or imaging center.

via Personalized CBCT Education.

General Radiography

Digital Radiography Myths

XDR Sensor


The thinnest sensors are the most comfortable.

Fact: This seems to make sense but on examination it is just silly. With this logic pressing a knife blade into your hand would be more comfortable than pressing a spoon. After all, the knife is thinner. Within the range of all sensors on the market, that is 2-4mm thick, the patient acceptance is the same.

Myth: The cord is a problem.

Fact: The cord simply needs to come out of the mouth it can’t go down the throat. If you can master a saliva ejector you can handle the cord on the sensor.

Myth: It will cost $40,000 for a digital x-ray system.

Fact: It is quite possible to get a digital x-ray system for $12,000 or less. A good name brand sensor will cost about $8,000 and good software around $4,000. If you want to shop price you could get a system for under $10,000.

Myth: The price will be coming down soon.

Fact: Prices have been going up. The economies of scale which have driven down the price of many high tech products simply do not apply to digital x-rays. There is no general consumer demand outside of dentistry. The market is limited, and the cost of development, service and support is very high.

Myth: The staff won’t like it.

Fact: 50,000 plus dental offices are successfully using digital radiography. If the staff doesn’t like it, the problem may be the staff not the system. Most staff resistance problems are really training problems.

Myth: I need a sensor in every room.

Fact: Most general dental offices can start quite well with just one sensor. The sensor is not only a film substitute it is also a processor substitute. If you can run your dental practice with one film processor you can run the office with one sensor. Multiple doctor offices or offices with lots of pediatric patients may need a second sensor.

Myth: Wireless phosphor storage systems are less expensive than corded systems.

Fact: Corded systems cost less. As shown above a basic corded system with software is $12,000. Name brand phosphor systems with software are usually more than $20,000.

Myth: All the sensors are the same.

Fact: All the sensors will deliver an adequate diagnostic image but they are not the same. Sensor reliability varies significantly. Check the warranties for an idea regarding reliability. Image quality varies. Do a side by side comparison or check independent research for comparisons. It isn’t just the sensor but the company behind it and the training service and support that goes with it that makes a difference.

Myth: Digital x-rays aren’t as good as film.

Fact: Digital x-rays are not the same as film. But that is OK. What we really want is not something that is just like film what we should really want is something that is diagnostic. Based on that criterion, digital radiographs have more data than films and the image can be enhanced with processing software to improve diagnostics.

Myth: The future seems uncertain.

Fact: The future is coming and it will be amazing!

For more information

Diagnostics Radiography

What’s a Voxel?

What the heck is a voxel…and why should you care?

A voxel is to a 3D image as a pixel is to a flat 2D image. It is a measure of space.

This matters if you are considering a come beam CT. The CBCT will render the image in voxels. As a general rule the smaller the voxel size the more detail (or resolution) the image can present. However, as is often the case, it just isn’t that simple. There are many other factors which will determine the resolution and the clarity of a CBCT image.

These other factors range from how tightly the patient’s head is held in place to the proprietary internal software in the machine that creates the voxel to begin with.

For more information visit Cone Beam Guru Dale Miles.

Management Radiography

Digital Radiography ROI

The number one reason dentists resist investing in a digital radiography system is the expense. The link below is to a calculator you can use to determine the ROI on digital radiography.

DEXIS: Digital X-ray for Dental Practitioners.

Contrary to many dentists beliefs digital radiography is considerably less expensive than old fashioned chemical film radiography.

For example, I talk with many dentists who believe the cost to get started with digital radiography is at least $40,000. That is nowhere near the true cost which is closer to $10,000 to $12,000 for a sensor and software.

Compare that to a film processor which has a cost of $8,000 which is about the cost of a sensor; plus the expense of building and setting up a dark room. The fact is the initial cost of a film system or a digital system is almost the same.

However the real savings is in ongoing expense. Various studies show the cost of a single film radiograph to be between 60 cents to as much as a dollar each. (Film, mounts, chemicals, disposal and time) On the other hand the incremental cost of a digital radiograph is almost nothing.


Diagnostics Software

Logicon Software

LOGICON Software is clinically proven to help dentists find up to 20% more interproximal caries on permanent teeth than traditional methods.* The new Autoscan feature automatically scans proximal surfaces and highlights decay sites in one picture, while detailing and saving changes in tooth density and lesion probability for each surface.

via Diagnostic Radiology | Logicon Software | Diagnostic Imaging.

This represents the future of diagnostics. Not only will we use a detector to determine a physiological change in a human tissue (Like enamel) we will use software to analyze the change and give us a likely diagnosis.

As difficult as it is for us to admit the computer sensor and the software can detect changes in enamel density that are too subtle for us to see with an unaided human eye.