Digital Radiology 2009 Juan F. Yepes, D.D.S., M.D., M.P.H.

Digital Radiology 2009 Juan F. Yepes, D.D.S., M.D., M.P.H.
Assistant Professor Director of Oral and Maxillofacial Radiology Division of Oral Diagnosis, Medicine and Radiology Department of Diagnostic Radiology Chandler Medical Center

Digital Radiology CBCT CT – MRI Cases ODM 880 2009

Outline / Objectives Types of Systems How it works ?
Available Products Financial Disclosure

“Sharpen your diagnostic ability.”
Some comments…… “Sharpen your diagnostic ability.” “...immediately enhance your diagnostic capabilities.”

“. the low dosage [sic] requirement
“...the low dosage [sic] requirement....means that you can afford one or two extra control pictures for root fillings or other complex jobs.”

“Increase treatment acceptance with our HANDheld computer that every patient can see.”

“The microprocessor controlled timer will automatically adjust the exposure time to take perfect quality x-rays.”

“The [name of unit] x-rays exceed the international standards for total radiation safety...up to 95% less scatter radiation than the government allows.”

“I simply let. [the patients]
“I simply let ...[the patients]...know that they’ll be getting about 90% less radiation than they would from a standard x-ray.”

“The images come up instantly as patients are in the chair; the images are so large that patients can’t help but become involved in the diagnosis. I never expected them to be so enthusiastic.”

“Most patients are amazed at how quickly the image comes up on the screen and are impressed by its size.”

“I don’t spend a lot of time trying to sell the technology
“I don’t spend a lot of time trying to sell the technology. I simply let patients know what it is and let them see the images.”

“I use the contrast change regularly
“I use the contrast change regularly....I shift through all the variances of gray scale. This allows me to find pathologies that might not otherwise be evident”

“...requires much lower exposure-times than film thus reducing the patient’s radiation consumption dose.”

“I always let. [the patients]. know that
“I always let ...[the patients]...know that ... I can diagnose more accurately and precisely than with traditional radiographs.”

“Patients will view the the doctor as making a more accurate diagnosis by using improved technology.”

“There is potential for a tremendous flow of new patients, since approximately 50% of the population does not regularly visit a dentist...

When new patients arrive, many of them have acute problems
...When new patients arrive, many of them have acute problems. This is the time to begin to use the technology...

...Take the initial radiographs and examine the acute problem when the patient arrives in the practice...

... The images can be immediately brought up on the screen for the patient to view and it can be magnified from 100% to 300%.”

“It combines superior design with outstanding performance, resulting in perfect quality x-rays.”

“It’s been more than 100 years since X-rays were invented.”

Standard Radiographs Image receptor: film
Image processing: photochemical (developing, fixing, washing/rinsing, drying) Viewing: radiograph on illuminator Storage: radiograph

Digital Images Image receptor: CCD or screen
Image processing: cpu and software or laser, cpu and software Viewing: image on screen or print-out Storage: on disk or paper hard copy

Advantages/Disadvantages Radiographs vs. Digital Images
portable not portable* familiar new technology* can be viewed by all must have hardware/software initially inexpensive inexpensive after initial investment must send by mail transmissible by wire* one viewer or duplicate (duplitized) viewed simultaneously

Advantages/Disadvantages Digital Images: new technology = uncertainty

no inherent measurements software driven measurements film size similar to beam size receptor size smaller than beam size (DR/cable systems) film covers larger area receptor covers smaller area (DR/cable systems)

EPA film disposal no film disposal EPA chemical/silver disposal/recovery no chemicals film placement is easy cable connection interferes with placement (CCD) easy to view multiple images (shuffling) awkward to view multiple images (shuffling)

caries detection caries detection* periodontal bone loss periodontal bone loss periapical bone loss periapical bone loss complete mouth survey complete mouth survey* bony lesions bony lesions poor for soft tissue lesions soft tissue lesions?

Dental Digital Imaging:
Where are we as of January 2009?

Status of Current Technology (500 dentist)
30 + different brands of equipment are in use 61% of dentist paid $ 10,000 - $ 30,000 for the system 76% of the dentist in USA would purchase the same system again 80% of dentist in USA reported that the image quality and diagnostic capabilities were similar to or better than conventional radiology Image enhancement tools used most were: magnify, enhance, contrast and inverse

Status of Current Technology (500 dentist)
Major advantages: instant image, patient communication, image enhancement, no processing, less radiation, image magnification Major disadvantages: high cost, uncomfortable sensors, poor image quality, difficult to learn and implement, dependent on computer, technical problems 89% of dentist in USA using digital radiology recommended that colleagues switch to digital now rather than continue to wait

1895: Wilhelm Conrad Roentgen  X-rays
Filmless Imaging 1895: Wilhelm Conrad Roentgen  X-rays Two weeks after: Otto Walkoff: First dental x-ray ALARA principle “As low as reasonably achievable” 1980: First digital x-ray sensor for use in dentistry 2006: End of the film-base radiology?

Digital Imaging: Most significant advantages:
- Computer-aided image interpretation - Image enhancement - Image archiving - Image retrieval

Digital Imaging More Advantages Chemical processing Hazardous wastes Images can be transferred electronically Patient Education Time Less Radiation One thousand more depending of the vendor

Digital Imaging Disadvantages Cost Susceptible to use and abuse Obsolete very fast System crash Same geometry limitations than conventional radiology - Storage and back up

Digital System  numeric
Digital Imaging BASIC PRINCIPLES Spatial Distribution of the picture elements  PIXEL Different shades of gray PIXEL Digital System  numeric

Digital Imaging Each pixel has a row and a column coordinates that identifies its location in the matrix

How the image is produced?
Digital Imaging How the image is produced? Pixel  Electronic Detector  Absorption of x-rays  Generates a small voltage X-rays electron

How the image is produced?
Digital Imaging How the image is produced? Production of the digital imaging X-rays Maximum Minimum electron (analog system)

What is a Digital Imaging?
Pixel: the photon intensity is measured electronically on a scale of 256 gray values (0-255) 0= maximum radiation (black) 255= minimum radiation (white) -The measurements of the photon intensities for each pixel are sent to the computer an stored as an array of numbers representing the x and y coordinates.

Digital Imaging How the image is produced? X-rays  Patient  Receptor  Image  Detection INTERPRETATION!!

Digital Imaging Direct system CCD Charge – Couple - Device 2. CMOS Complementary metal oxide semiconductors PSP Photo-stimulable-phosphouros plates Direct system Digital Detectors Indirect system

Electronic chip used to capture the image
Filmless Imaging CCD Solid-state sensor Electronic chip used to capture the image The chip converts into an electronic signal the energy of the x-ray photons hitting the sensor -To increase the efficiency scintillation layer: converts x-ray photons into light photons

CCD  Introduced to dentistry in 1987
Digital Imaging CCD  Introduced to dentistry in 1987 Covalent bonds between atoms are broken producing ELECTRONS Number the electrons is proportional to the amount of exposure that an area receives X-RAY Silicon

Digital Imaging How CCD works? Electrons are attracted toward the most positive potential and create “charge packets”  1 PIXEL Data is transferred in rows  Cable  Computer Wireless systems

Charge-Coupled Devices
CCD/CMOS/Flat panel (cable)

C.C.D. with Scintillation Layer X R A Y S ELECTRONIC MESSAGE C.C.D.

How CCDs Work

Complementary metal oxide semiconductors
Digital Imaging CMOS Complementary metal oxide semiconductors Different from CCDs in the way that pixel charges are read Each pixel is directly connected to the transistor Each pixel generates electrons in proportion to the amount of x-ray energy that is absorbed -Voltage is display independently on the screen

CMOS chip: more of the electronic components
Filmless Imaging CMOS Solid-state sensor CMOS chip: more of the electronic components controlling the conversion of photon energy into the electronic signal are incorporated into the chip -Chip: less expensive, simple production process -CCD and CMOS comparable image quality

Charge-Coupled Devices
CCD/CMOS/Flat panel (cable)

Units Available CR (Computed Radiography) PSP/SP
Photo-stimulable-phosphorous plates Plates absorb and store energy from x-rays and the release of this energy as light when stimulated by other light

Phosphor layer  store the energy of the x-ray photons
Filmless Imaging PSP Phosphor layer  store the energy of the x-ray photons A scanner is required to read the image The energy is released and detected by an imaging intensifier and subsequent converted into digital imaging -The latent image will remain in the PSP before the scanning phase for minutes to hours.

How PSPs/SPs Work e- e- e- e- e- e- e- e- e- e- e- e- e- e- e- e-

europium-activated barium fluorohalide
How PSPs/SPs Work Photostimuable/Storage phosphors europium-activated barium fluorohalide

europium-activated barium fluorohalide
How PSPs/SPs Work europium-activated barium fluorohalide

How PSPs/SPs Work X R A Y S e-

Choosing a System…. Type of practice Type of patients Money Storage Insurance Software Hardware Staff Previous experiences CCD and CMOS PSP Extra-Oral systems

Dose Reduction It is considered to be one of the most important advantages of digital radiology……However: Intraoral versus extraoral PSP: can provide a good images even when the exposure time has been much greater than the require for film-base imaging  the user is not warned by an unsatisfactory image -CCD and CMOS: small exposure range

Security Aspects Possibility to change the look of digital radiograph Storage of the original film Concept of “watermarks” Detection of altered images Film base versus digital radiology

Implementation of Digital Radiology

Intraoral Systems

Intraoral Systems DR/Cable Systems RVG 6100
Kodak Dental System Group Computed Digital Radiography: CDR Schick Technologies SIDEXIS IO2 Sirona Dental Systems DEXIS DEXIS Digital X-Ray ImageRAYi Dentrix Lightyear (Light Year Technology)

Intraoral Systems DR/Cable Systems Sigma MDX Digital Sensor
Sigma Instrumentarium MDX Digital Sensor MediaDent VisualiX eHD Gendex Imaging Dixi-3 Planmeca Cleartooth Cleartooth Electronics

Intraoral Systems PSP Systems OpTimeA DenOptix QST ScanX
Soredex USA, DenOptix QST Gendex Imaging ScanX Air Techniques

Digital Radiography System
General Considerations Existing set-up in your office: x-ray machine, computer equipment, and practice manager software Electronic transfer capabilities DICOM – complaint systems Hands-on session with the vendors

Factors that might influence your purchasing decision:
Sensors: Size Shape Positioning devices Software features X-ray generator 16 – inch collimator Rectangular

Factors that might influence your purchasing decision:
Computer equipment: Processor System memory (RAM) Hard disk space Practice Management: DICOM compliance:

Problems Comparing Systems
Articles comparing systems no longer up-to-date Systems compared to D speed or E speed film Dose reductions compared to what exposure of films

Problems Comparing Systems
Manufacturers unable to provide answers Manufacturers unwilling to provide answers Manufacturers providing incorrect answers Manufacturers providing inconsistent answers Manufacturers changing products on the fly

ADA in 2006 evaluated 7* direct digital system:
DIXI 3 Planmeca CDR Schick Technologies Image RAYi Dentrix Dental System RVG Kodak Dental Systems Sigma Instrumentarium Dental, Inc. VisualiX eHD GENDEX Dental Systems DEXIS * Dexis LCC 19 clinicians under standard conditions for interpretation

Perceptibility Test CDR 93.2 88.9 98.9 DIXI 86.3 80.0 ImageRAYi 93.7
Accuracy, Sensitivity, and Specificity of Evaluated Systems Accuracy Sensitivity Specificity CDR 93.2 88.9 98.9 DIXI 86.3 80.0 ImageRAYi 93.7 91.1 RVG 94.0 100 Sigma 88.6 82.9 VisualiX 86 81.1 95.8

Image Quality Test Clinical Significance: To compare the ability of different systems to depict normal dental structures as evaluated by dentist evaluators Each dentist viewed each set of four images and selected one image for each system that she or he judged as offering the highest diagnostic quality** Diagnostic Quality: The ability to identify the dentin-enamel junction, PDL space, pulp chamber and root canals

CDR 6 6.37 ImageRAYi 5 5.11 RVG 6000 4 4.79 VisualiX 3 4.47 Sigma 2
Score Average score CDR 6 6.37 ImageRAYi 5 5.11 RVG 6000 4 4.79 VisualiX 3 4.47 Sigma 2 4.05 DIXI 3 1 2.32 Image Quality Test

ADA Professional Product Review
Which one of the following digital radiography systems do you use most often? N=161

A comparison of 18 different x-ray detectors currently used
In dentistry Purpose: Provide a basic comparison of spatial resolution, contrast perceptibility, and relatively exposure of 18 current dental x-ray detectors Methods: Spatial resolution  Phantom test grid Contrast perceptibility  aluminum perception test device Relatively exposure  expert consensus of the clear discrimination of the ED junction Results: Highest spatial resolution: Kodak RVG 6000 – Planmeca Dixi Contrast resolution: Kodak RVG 6000 – Visualix eHD Relatively exposure: PSP – Kodak RVG 6000 AG Farman, TT Farman, OOOO 2005

Kodak Dental Film

Standard Dental X-ray Films
2 1 3 54 x27 35 x 22

Comparison of Intraoral Systems
“I” Sensor Configurations RadioVisioGraphy: RVG 6100 Computed Digital Radiography: CDR SIDEXIS IO2 Lightyear (lightyear technology)

Comparison of Intraoral Systems
“Q” Sensor Configurations DEXIS

RVG 6100 Cost $ 13,895 Warranty 3 years Sensor size # 0 # 1 and # 2
Extraoral options Yes Sensor Comfort Fair Ease to Set-up Excellent Speed Excellent Enhancement tools E Features: Very good image quality Excellent enhancement tools Sensor can be soaked Overall grade: 3.6 Clinician guide to Dental Products and Technology

Logicom ®

Dexis ® Cost $ 13,995 Warranty 1 years Sensor size # 2
Extraoral options Yes Sensor Comfort Good Ease to Set-up Excellent Speed Excellent Enhancement tools Good Features: Good sensor comfort Good image quality Optimized for laptop Overall grade: 3.5 CRA Foundation

DEXIS Receptor vs. #1 and 2 Dental X-ray Films

DEXIS Receptor

ImageRAYi (Dentrix) Cost (kit) $ 13,090 Enhancement tools Excellent
Warranty 2 years Sensor size # 1 and # 2 Extraoral options None Sensor Comfort Fair Ease to Set-up Excellent Speed Good (10 sec) Enhancement tools Excellent Features: Minimum radiation Excellent image quality Excellent enhancement tools Overall grade: 3.4 CRA Foundation

CDR (Schick Technologies))
Cost (kit) $ 11,764 Warranty 2 years Sensor size # 0, # 1 and # 2 Extraoral options Yes Sensor Comfort Fair Ease to Set-up Excellent Speed Excellent (3 sec) Enhancement tools Good Features: Good image quality Wireless option SDX x-ray head available Overall grade: 3.4 CRA Foundation

CDR Receptor vs. #0, 1 and 2 Dental X-ray Films

CDR Plus Wire ®

Sidexis XIOS (Sirona Corporation)
Cost (kit) $ 12,560 Warranty 2 years Sensor size # 1 and # 2 Extraoral options Yes Sensor Comfort Good Ease to Set-up Excellent Speed Excellent (3 sec) Enhancement tools Fair Features: Good sensor comfort Minimum radiation Overall grade: 3.1 CRA Foundation

SIDEXIS Receptor vs. #1 and 2 Dental X-ray Films

Lightyear Cost (kit) $ 9,995 Enhancement tools Fair Warranty 5 years
Sensor size # 0, # 1 and # 2 Extraoral options Yes Sensor Comfort Poor Ease to Set-up Excellent Speed Good (10 sec) Enhancement tools Fair Features: Lowest cost 5 year warranty Overall grade: 2.8 CRA Foundation

Sigma – Snapshot (Instrumentarium)
Cost (kit) $ 11,920 Warranty 2 years Sensor size # 1 and # 2 Extraoral options Yes Sensor Comfort Good Ease to Set-up Excellent Speed Excellent (3 sec) Enhancement tools Excellent Features: Good sensor comfort Sensor can be soaked Overall grade: 3.6 CRA Foundation

Dixi ® (Planmeca) Cost (kit) $ 12,661 Enhancement tools Excellent
Warranty 2 years Sensor size # 0, # 1 and # 2 Extraoral options Yes Sensor Comfort Fair Ease to Set-up Excellent Speed Excellent (3 sec) Enhancement tools Excellent Features: Good sensor comfort Sensor can be soaked X-ray head available Overall grade: 3.6 CRA Foundation

Planmeca Dixi ® Receptors

Dr. Suni (Suni medical Imaging)
Cost (kit) $ 9,661 Warranty 1 years Sensor size # 0, # 1 and # 2 Extraoral options Yes Sensor Comfort Good Ease to Set-up Excellent Speed Good (8 sec) Enhancement tools Excellent Features: Minimum radiation Thin sensor Overall grade: 3.1 CRA Foundation

OPTime (Sorodex USA) PSP
Cost (kit) $ 11,600 Warranty 2 years Sensor size # 0, # 1 # 2 # 3 Extraoral options Yes Sensor Comfort Good Ease to Set-up Excellent Speed Good (49 seconds) Enhancement tools Excellent Features: Very good image quality Easy clinical implementation Single plate scanner Overall grade: 3.0 CRA Foundation

OPTime Receptor vs. #0 and 2 Dental X-ray Films

DenOptix QST (Gendex Imaging) PSP
Cost (kit) $ 13,995 Warranty 2 years Sensor size # 0, # 1 # 2 # 3 Extraoral options Yes Sensor Comfort Good Ease to Set-up Excellent Speed Good (92 seconds) Enhancement tools Excellent Features: Very good image quality Easy clinical implementation Carrousel scanner Overall grade: 2.7 CRA Foundation

DenOptix Receptor vs. #1 and 2 Dental X-ray Films

DenOptix Receptor vs. #0 and 2 Dental X-ray Films

Imaging plates the size of dental film
Gendex DenOptix Imaging plates the size of dental film

Imaging plates are flexible
Gendex DenOptix Imaging plates are flexible

Holders similar to dental film
Gendex DenOptix Holders similar to dental film

Load plates onto scanning carousel
Gendex DenOptix Load plates onto scanning carousel

Gendex DenOptix Can scan up to 29 plates at one time. There are intra- and extraoral plates and carousels

ScanX (Air techniques) PSP
Cost (kit) $ 19,995 Warranty 2 years Sensor size # 0, 1, 2, 3, 4 Extraoral options Yes Sensor Comfort Fair Ease to Set-up Excellent Speed Good (57 seconds) Enhancement tools Excellent Features: Very good image quality Easy clinical implementation Overall grade: 3.1 CRA Foundation

Intraoral plates on scanning drum
DENT-X Scan-A-Ray 500 Intraoral plates on scanning drum

Can scan only 6 plates at one time.
DENT-X Scan-A-Ray 500 Can scan only 6 plates at one time. Scan time: 50 sec.

So, what should I look for?

So what should I look for...?
Do I need this now? What comes with the price? Is the image format proprietary? Can I communicate with other practitioners (or other offices)? If so, can I (or they) manipulate the image?

How easy is it to back up the images? Do the insurance carriers that I deal with accept digital images, and how? Is the image varifiable (for alteration)? Can I process multiple images from different patients, and split them? What about a warranty (and with whom)?

Is the image compressed or noncompressed? Can I get upgraded software and if so, what would it cost? Will there be upward compatibility of images? How is servicing handled? Cost, availability, time to arrive?

Digital Radiology 2009 Juan F. Yepes, D.D.S., M.D., M.P.H.

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Digital Radiology 2009 Juan F. Yepes, D.D.S., M.D., M.P.H.

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