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.

Diagnostics Digital Impressions Management Theraputics

SomnoDent and Digital High Tech

A SomnoDent sleep apnea oral appliance is a premium, custom-fitted dental device developed for the treatment of snoring and obstructive sleep apnea. It is an effective, comfortable, and durable alternative to CPAP therapy or corrective surgery.

Source: Sleep Apnea Oral Appliance – SomnoMed

Sleep therapy lends itself well to digital technology. We are using the following for our sleep patients:

  • i-Cat CBCT for a general dental evaluation and measurement of the airway.
  • 3 shape TRIOS scanner and software to take a full upper and lower impression as well as a digital bite.
  • Telemedicine for the medical consult needed for a diagnosis and treatment plan.
  • SleepMed ARES home sleep test, remarkable technology that tests the patient for OSA at home rather than at an expensive sleep clinic.

The technology is amazing and works well. The SomnoDent device is simple and effective.

The most challenging part of the process by far is the paperwork and dealing with medical insurance.


Digital Radiography Guide

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 the move to 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.

Office Design Radiography

Hand Held X-Rays Goes Anywhere.

nomadI am a big fan of the Nomad hand held x-ray device from Aribex. Interestingly the inventor, Dr. Clark Turner started out looking for a completely portable x-ray unit for use in missionary work. Nomad can be used in mobile clinics, nursing homes, hospital wards, missionary work, and even forensics.

However it is also great for use in a dental office. A single Nomad can take the place of at least three or maybe four wall mounted units. That means not only is it more flexible but overall it costs less.


Digital Radiography Training

train3There are three separate areas that will require training for the doctor and staff in order to use digital radiography well. These are:

  1. General use of the software. This would include how to open it, how to find a patient, how to find a specific radiograph and how to copy or print the images.
  2. How to take a radiograph. This would include setting up the software and the sensor to take an image, positioning the sensor, setting up and positioning the X-Ray unit, then capturing and saving the image to the proper patient record.
  3. How to process and enhance an image. This would include using the various tools to find an image and then to optimize it for diagnosis.

Each person in the office should have a good understanding of the entire system. However each person will have a special area he/she needs to master.

Dentist: The dentist needs to be able to launch the software, find a patient record and take a radiograph if needed. However the doctor’s primary duty is to examine the image and make a diagnosis. For that reason the dentist needs to understand the enhancement tools and learn which tools will help with diagnosis.

Assistant: The dental assistant needs to be able to launch the software, find a patient record, find the proper radiograph for the procedure and then display it for the dentist to refer to during treatment. The assistant will also need to know how to set up and take an image.

Hygienist: The dental hygienist takes most of the radiographs in a typical office. He/she will need to know how to launch the software and find a patient record. But beyond that he/she will need to know how to quickly and accurately take an image. If  there are problems he/she will need to know how to correct the problems in order to get a proper diagnostic image.

Administrator: The front desk person does not need to know the clinical procedures of capturing and diagnosing an image. However the administrator will need to know how to find the proper image and copy or transmit it to another party such as an insurance carrier a dental specialist or even to the patient.

For more help with Digital Radiography look here and here.

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.


Printing a Digital X-Ray

The secret to printing digital x-rays can be found in an old Nike ad.

Just Don’t Do It

When you hand a printed radiograph to an experienced (old) dentist the first thing he/she does is hold it up to the light to look through the solid paper. That makes as much sense as printing it in the first place, and is done for the same reason. That’s just the way we’ve always done 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. Ideally images transmitted between professionals should be HIPAA compliant and follow the DICOM protocol.

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.

For more help with Digital Radiography look here:

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.


Fuzzy no More

One of the best things about a digital x-rays is that they are…wait for it…they are…digital! That means we can use diagnostic software to examine and possibly enhance the image and improve our diagnostic efficiency. Most dentists believe that digital radiography is all about the sensor, but when it comes to diagnosis it is all about the software.

With digital radiography we tend to forget we can enhance the image; we are used to analyzing a similar non digital film image with our eyes so we don’t easily appreciate the software analysis. Most dentists in fact just analyze and diagnose from the raw digital radiograph with their eyes. Just as they did film in the past; it just seems like a different version of the same old diagnostic.

Here is an example of how software can enhance diagnostics. These images are from the XDR Radiography system.

Above is a raw image straight from the sensor. Can you detect interproximal decay? Most dentists can see the lesions but we feel the image is “fuzzy” not as clear as we are used to with film.

Now look at the same image after a “sharpening” tool has been applied.

The sharpened image is more like film and most dentists find it better diagnostically. Interestingly the sharpening tool extracts data to make grayscale changes more abrupt. Here is what Dr. Doug Yoon a dentist and the brains behind XDR Radiography says about sharpening.

“I think sharpening can serve as a visualization aid by making the fuzzy borders of lesions look more distinct (even though we all know lesions really do have fuzzy borders).”

The point to remember is that a primary advantage of a dgital image is that it can be enhanced with software. Don’t judge digital radiography by the image alone it is both a high quality image and good diagnostic software that makes digital better than film.


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.


Pro Vecta S-Pan

ProVectaSPan00My friend Dr. Dale Miles (who knows a whole lot more about digital imaging than I do) really likes this new pan.

From a single exposure, only S-Pan acquires 20 layers of images and slices them into 20,000 fragments. The best are selected and compiled to generate a single, exceptionally sharp panoramic image–automatically!

via Air Techniques.

The problem with dental panoramic radiographs has always been the curve and thickness of the mandible. Everybody is a bit different from everybody else, however the system has to focus the x-ray beam somewhere. In the past manufacturers have chosen averages and sometimes you get a clear diagnostics image and sometimes…not so much.

The S-Pan uses digital technology to take twenty different layers then combine them as needed to get the best image. In a sense the software customizes the image trough to each person.

Check out Dr. Miles website here.

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.

CAD CAM General Hardware Radiography

Proprietary vs. Interoperability

Definitions from Webopedia

Interoperability:  The ability of software and hardware on different machines from different vendors to share data.

Proprietary:  Privately owned and controlled. A proprietary design or technique is one that is owned by a company. It also implies that the company has not divulged specifications that would allow other companies to duplicate the product.

You can see a real world example of interoperability with consumer electronics. A user can buy a Phillips TV, plug it into a Toshiba DVD, add speakers from Bose and play a Sony DVD from Japan to watch a movie made in Hollywood and it all works together.

For an example of a typical proprietary system, consider the imaginary digital radiography system, ProprioRay. It will only work with the ProprioRay sensor plugged into a ProprioRay connector. The image can only be captured and displayed using ProprioRay software and images are stored in a proprietary ProprioRay format.

More recently we have been introduced to the imaginary CAD CAM system Ceroscan. You can only use a Ceroscan camera plugged into a Ceroscan computer running Ceroscan software. You can not transfer the digital impression to another software or to  a mill or lab of your choice you must use a Ceroscan mill and Ceroscan approved labs. Ceroscan even has a restricted version of the Internet you must use with their products.

Manufacturers like proprietary systems. Consumers prefer interoperability. Experience has shown that vendors will attempt to maintain control unless consumers demand interoperability. When you do they will try and tell you why it is actually to your benefit that they keep you hostage in their private garden.


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.

Diagnostics Radiography

Dale Miles on Cone Beam CT


The best way to print digital X-rays




Don’t do it.




More help choosing and using Digital Radiography