juan f. yepes, d.d.s., m.d., m.p.h. assistant professor director of oral and maxillofacial radiology...
TRANSCRIPT
Juan F. Yepes, D.D.S., M.D., M.P.H.Assistant Professor
Director of Oral and Maxillofacial RadiologyDivision of Oral Diagnosis, Medicine and Radiology
Department of Diagnostic RadiologyChandler Medical Center
Digital Radiology 2009
ODM 880
2009
Digital Radiology
CBCT
CT – MRI
Cases
1. Types of Systems
2. How it works ?
3. Available Products
Outline / Objectives
Financial Disclosure
“Sharpen your diagnostic ability.”
“...immediately enhance your diagnostic capabilities.”
Some comments……
“...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]...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 simply let patients know what it is and let them see the images.”
“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 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. 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/DisadvantagesRadiographs vs. Digital Images
• portable • not portable*• familiar• can be viewed by all
• initially inexpensive
• must send by mail• one viewer or
duplicate (duplitized)
• new technology*• must have
hardware/software• inexpensive after
initial investment• transmissible by wire*
• viewed simultaneously
Advantages/DisadvantagesDigital Images: new technology = uncertainty
Advantages/DisadvantagesDigital Images: new technology = uncertainty
Advantages/DisadvantagesDigital Images: new technology = uncertainty
Advantages/DisadvantagesDigital Images: new technology = uncertainty
Advantages/DisadvantagesDigital Images: new technology = uncertainty
Advantages/DisadvantagesDigital Images: new technology = uncertainty
Advantages/DisadvantagesDigital Images: new technology = uncertainty
Advantages/DisadvantagesDigital Images: new technology = uncertainty
Advantages/DisadvantagesDigital Images: new technology = uncertainty
Advantages/DisadvantagesDigital Images: new technology = uncertainty
Advantages/DisadvantagesDigital Images: new technology = uncertainty
Advantages/DisadvantagesDigital Images: new technology = uncertainty
Advantages/DisadvantagesDigital Images: new technology = uncertainty
Advantages/DisadvantagesRadiographs vs. Digital Images
• no inherent measurements
• software driven measurements
• film size similar to beam size
• film covers larger area
• receptor size smaller than beam size (DR/cable systems)
• receptor covers smaller area (DR/cable systems)
Advantages/DisadvantagesRadiographs vs. Digital Images
• EPA film disposal • no film disposal• EPA chemical/silver
disposal/recovery• film placement is easy
• easy to view multiple images (shuffling)
• no chemicals
• cable connection interferes with placement (CCD)
• awkward to view multiple images (shuffling)
Advantages/DisadvantagesRadiographs vs. Digital Images
• caries detection • caries detection*• periodontal bone loss• periapical bone loss
• complete mouth survey
• bony lesions
• poor for soft tissue lesions
• periodontal bone loss• periapical bone loss
• complete mouth survey*
• bony 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
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 Imaging
BASIC PRINCIPLES
Digital System numeric
Spatial Distribution of the pictureelements PIXEL
Different shades of gray PIXEL
Digital Imaging
Each pixel has a row and a column coordinates thatidentifies its location in the matrix
Digital Imaging
How the image is produced?
Pixel Electronic Detector Absorption of x-rays Generates a small voltage
electron
X-rays
Digital Imaging
How the image is produced?
electron
X-rays
Maximum
Minimum
(analog system)
Production of the digital imaging
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
Digital Detectors
1. CCDCharge – Couple - Device
2. CMOSComplementary metal oxide semiconductors
3. PSPPhoto-stimulable-phosphourosplates
Direct system
Direct system
Indirect system
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
Digital Imaging
CCD Introduced to dentistry in 1987
Silicon
Covalent bonds between atomsare broken producing ELECTRONS
Number the electrons is proportionalto the amount of exposure that anarea receives
X-RAY
Digital Imaging
Electrons are attracted toward the most positivepotential and create “charge packets” 1 PIXEL
Data is transferred in rows Cable Computer
Wireless systems
How CCD works?
CCD/CMOS/Flat panel (cable)
Charge-Coupled Devices
C.C.D. with ScintillationLayerX R A Y S
ELECTRONIC MESSAGEELECTRONIC MESSAGEC.C.D.
SCINTILLATION LAYER
How CCDs Work
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
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
CCD/CMOS/Flat panel (cable)
Charge-Coupled Devices
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
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
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Photostimuable/Storage phosphors
How PSPs/SPs Work
europium-activated barium fluorohalide
How PSPs/SPs Work
europium-activated barium fluorohalide
How PSPs/SPs Work
X R A Y S
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Choosing a System….
CCD and CMOS
PSP
Extra-Oral systems
- Type of practice- Type of patients- Money- Storage- Insurance- Software- Hardware- Staff- Previous experiences
Dose Reduction
It is considered to be one of the most importantadvantages 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 SystemsDR/Cable Systems
• RVG 6100Kodak Dental System Group www.kodak.com/dental
• Computed Digital Radiography: CDRSchick Technologies 800-645-4312
• SIDEXIS IO2Sirona Dental Systems 800-659-1505
• DEXISDEXIS Digital X-Ray 888-883-3947
• ImageRAYiDentrix 800-336-8749
• Lightyear (Light Year Technology) 1-678-990-4030
Intraoral SystemsDR/Cable Systems
• SigmaSigma Instrumentarium 800-558-6120
• VisualiX eHDGendex Imaging 1-888-275-5286
• Dixi-3Planmeca 630-595-7077
• MDX Digital SensorMediaDent 800-868-5038
• CleartoothCleartooth Electronics 1-800-206-4557
• OpTimeA Soredex USA, 1-800-558-6120
• DenOptix QSTGendex Imaging 1-800-769-2909
• ScanX Air Techniques 1-800-247-8324
Intraoral SystemsPSP Systems
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 ShapePositioning devices
• Software features
• X-ray generator 16 – inch collimatorRectangular
Factors that might influence your purchasing decision:
• Computer equipment: ProcessorSystem 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 6000 Kodak Dental Systems• Sigma Instrumentarium Dental, Inc.• VisualiX eHDGENDEX Dental Systems• DEXIS * Dexis LCC
19 clinicians under standard conditions for interpretation
Perceptibility TestAccuracy, Sensitivity, and Specificity of Evaluated Systems
CDR 93.2 88.9 98.9
DIXI 86.3 80.0 98.9
ImageRAYi 93.7 91.1 98.9
RVG 94.0 91.1 100
Sigma 88.6 82.9 100
VisualiX 86 81.1 95.8
Accuracy Sensitivity Specificity
Image Quality Test
Clinical Significance: To compare the ability of different systems todepict normal dental structures as evaluated by dentist evaluators
Each dentist viewed each set offour images and selected oneimage for each system that she orhe judged as offering the highestdiagnostic quality**
Diagnostic Quality: The ability to identify the dentin-enamel junction,PDL space, pulp chamber and root canals
Image Quality Test
CDR 6 6.37
ImageRAYi 5 5.11
RVG 60004 4.79
VisualiX 3 4.47
Sigma 2 4.05
DIXI 31 2.32
Score Average score
ADA Professional Product Review
CDR CMOS
DenOptix PSP
DIXI 3 CCD
Suni CCD
ImageRAYi CCD
Lightyear CCD
RVG 6000 CMOS
Scan X PSP
Sigma CCD
VisualiX CCD
Which one of the following digital radiography systems do you use most often?
N=161
A comparison of 18 different x-ray detectors currently usedIn dentistry
AG Farman, TT Farman, OOOO 2005
Purpose: Provide a basic comparison of spatial resolution, contrastperceptibility, and relatively exposure of 18 current dental x-raydetectors
Methods: Spatial resolution Phantom test gridContrast perceptibility aluminum perception test deviceRelatively exposure expert consensus of the clear
discrimination of the ED junction
Results: Highest spatial resolution: Kodak RVG 6000 – Planmeca DixiContrast resolution: Kodak RVG 6000 – Visualix eHDRelatively exposure: PSP – Kodak RVG 6000
Kodak
Dental Film
Standard Dental X-ray Films
35 x 22
40 x 24 41 x 31
54 x27
0 1 23
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
40 x 24
41 x 31
32 x 25.6
31 x 1.524 x 1.5
29.5 x 8.8
DEXIS Receptor vs. #1 and 2 Dental X-ray Films
DEXIS Receptor
ImageRAYi (Dentrix)
Cost (kit) $ 13,090
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
21x15 35 x 19 37 x 25
35 x 22 40 x 24 41 x 31
CDR Receptor vs. #0, 1 and 2 Dental X-ray Films
29 x 5
23 x 519 x 5
31 x 1.5
24 x 1.522 x 1.5
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
37.3 x 22.3
40 x 24
41 x 31
31 x 1.524 x 1.5
29.5 x 6
SIDEXIS Receptor vs. #1 and 2 Dental X-ray Films
Lightyear
Cost (kit) $ 9,995
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
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
31 x 1.5
22 x 1.5
35 x 1.6
26 x 1.6
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
40 x 24
41 x 31
40 x 24
41 x 31
DenOptix Receptor vs. #0 and 2 Dental X-ray Films
35 x 22
41 x 31
35 x 22
41 x 31
DenOptix Receptor vs. #0 and 2 Dental X-ray Films
31 x 1.5
22 x 1.5
31 x 1.6
22 x 1.6
Imaging plates the size of dental film
Gendex DenOptix
Imaging plates are flexible
Gendex DenOptix
Holders similar to dental film
Gendex DenOptix
Load plates onto scanning carousel
Gendex DenOptix
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
Can scan only 6 plates at one time.Scan time: 50 sec.
DENT-X Scan-A-Ray 500
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)?
So what should I look for...?
• 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?
So what should I look for...?