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 ODM 880 CBCT CT – MRI 2009 Cases Outline / Objectives 1. Types of Systems 2. How it works ? 3. Available Products Financial Disclosure Some comments…… “Sharpen your diagnostic ability.” “...immediately enhance your diagnostic capabilities.” “...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 exposuretimes 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/Disadvantages Radiographs vs. Digital Images • portable • familiar • can be viewed by all • not portable* • new technology* • must have hardware/software • initially inexpensive • inexpensive after • must send by mail initial investment • transmissible by wire* • one viewer or • viewed duplicate (duplitized) simultaneously Advantages/Disadvantages Digital Images: new technology = uncertainty Advantages/Disadvantages Digital Images: new technology = uncertainty Advantages/Disadvantages Digital Images: new technology = uncertainty Advantages/Disadvantages Digital Images: new technology = uncertainty Advantages/Disadvantages Digital Images: new technology = uncertainty Advantages/Disadvantages Digital Images: new technology = uncertainty Advantages/Disadvantages Digital Images: new technology = uncertainty Advantages/Disadvantages Digital Images: new technology = uncertainty Advantages/Disadvantages Digital Images: new technology = uncertainty Advantages/Disadvantages Digital Images: new technology = uncertainty Advantages/Disadvantages Digital Images: new technology = uncertainty Advantages/Disadvantages Digital Images: new technology = uncertainty Advantages/Disadvantages Digital Images: new technology = uncertainty Advantages/Disadvantages Radiographs vs. Digital Images • no inherent measurements • film size similar to beam size • film covers larger area • software driven measurements • receptor size smaller than beam size (DR/cable systems) • receptor covers smaller area (DR/cable systems) Advantages/Disadvantages Radiographs vs. Digital Images • EPA film disposal • EPA chemical/silver • no film disposal • no chemicals disposal/recovery • film placement is easy • cable connection • easy to view multiple interferes with placement (CCD) • awkward to view multiple images (shuffling) images (shuffling) Advantages/Disadvantages Radiographs vs. Digital Images • caries detection • periodontal bone loss • periapical bone loss • caries detection* • periodontal bone loss • periapical bone loss • complete mouth survey • complete mouth survey* • bony lesions • bony lesions • poor for soft tissue • soft tissue lesions? 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 Spatial Distribution of the picture elements PIXEL Digital System numeric Different shades of gray PIXEL Digital Imaging Each pixel has a row and a column coordinates that identifies its location in the matrix Digital Imaging How the image is produced? Pixel Electronic Detector Absorption of x-rays Generates a small voltage X-rays electron Digital Imaging How the image is produced? Production of the digital imaging X-rays Maximum electron Minimum (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 1. CCD Charge – Couple - Device Digital Detectors 2. CMOS Direct system Complementary metal oxide semiconductors Indirect system 3. PSP Photo-stimulable-phosphouros plates 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 Covalent bonds between atoms are broken producing ELECTRONS X-RAY Number the electrons is proportional to the amount of exposure that an area receives 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) X R A Y S C.C.D. with Scintillation Layer SCINTILLATION LAYER C.C.D. ELECTRONIC MESSAGE MESSAGE ELECTRONIC 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 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 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-ee-ee- -e--- e- e- e-eee-- ee e- e How PSPs/SPs Work Photostimuable/Storage phosphors europium-activated barium fluorohalide How PSPs/SPs Work europium-activated barium fluorohalide How PSPs/SPs Work X R A Y S e-ee-ee- -e- -e- e- e- ee-- ee e- e 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 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 www.kodak.com/dental •Computed Digital Radiography: CDR Schick Technologies 800-645-4312 •SIDEXIS IO2 Sirona Dental Systems 800-659-1505 •DEXIS DEXIS Digital X-Ray 888-883-3947 •ImageRAYi Dentrix 800-336-8749 • Lightyear (Light Year Technology) 1-678-990-4030 Intraoral Systems DR/Cable Systems •Sigma Sigma Instrumentarium 800-558-6120 •MDX Digital Sensor MediaDent 800-868-5038 •VisualiX eHD Gendex Imaging 1-888-275-5286 •Dixi-3 Planmeca 630-595-7077 •Cleartooth Cleartooth Electronics 1-800-206-4557 Intraoral Systems PSP Systems • OpTimeA Soredex USA, 1-800-558-6120 • DenOptix QST Gendex Imaging 1-800-769-2909 • ScanX Air Techniques 1-800-247-8324 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 upto-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 •CDR •Image RAYi •RVG 6000 •Sigma •VisualiX eHD •DEXIS * Planmeca Schick Technologies Dentrix Dental System Kodak Dental Systems Instrumentarium Dental, Inc. GENDEX Dental Systems Dexis LCC 19 clinicians under standard conditions for interpretation Perceptibility Test Accuracy, Sensitivity, and Specificity of Evaluated Systems Accuracy Sensitivity Specificity 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 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 Score Image Quality Test Average score CDR 6 6.37 ImageRAYi 5 5.11 4 4.79 3 4.47 2 4.05 1 2.32 RVG 6000 VisualiX Sigma DIXI 3 ADA Professional Product Review Which one of the following digital radiography systems do you use most often? CDR CMOS DenOptix PSP DIXI 3 CCD Suni CCD ImageRAYi CCD Lightyear CCD RVG 6000 CMOS Scan X PSP Sigma CCD VisualiX CCD 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 40 x 24 0 1 41 x 31 2 3 35 x 22 54 x27 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 Enhancement tools E Warranty 3 years Features: Sensor size Sensor Comfort # 0 # 1 and # 2 -Very good image quality -Excellent enhancement tools Yes -Sensor can be soaked -Overall grade: 3.6 Fair Ease to Set-up Excellent Speed Excellent Extraoral options Clinician guide to Dental Products and Technology Logicom ® Dexis ® Cost $ 13,995 Enhancement tools Good Warranty 1 years Features: Sensor size #2 Extraoral options Yes -Good sensor comfort -Good image quality -Optimized for laptop -Overall grade: 3.5 Sensor Comfort Good Ease to Set-up Excellent Speed Excellent CRA Foundation DEXIS Receptor vs. #1 and 2 Dental X-ray Films 40 x 24 32 x 25.6 41 x 31 DEXIS Receptor vs. #1 and 2 Dental X-ray Films 29.5 x 8.8 31 x 1.5 24 x 1.5 DEXIS Receptor ImageRAYi (Dentrix) Cost (kit) $ 13,090 Enhancement tools Excellent Warranty 2 years Features: Sensor size # 1 and # 2 Extraoral options None -Minimum radiation -Excellent image quality -Excellent enhancement tools -Overall grade: 3.4 Sensor Comfort Fair Ease to Set-up Excellent Speed Good (10 sec) CRA Foundation CDR (Schick Technologies)) Cost (kit) $ 11,764 Enhancement tools Good Warranty 2 years Features: Sensor size # 0, # 1 and # 2 -Good image quality -Wireless option -SDX x-ray head available -Overall grade: 3.4 Extraoral options Yes Sensor Comfort Fair Ease to Set-up Excellent Speed Excellent (3 sec) 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 5 19 x 5 31 x 1.5 24 x 1.5 22 x 1.5 CDR Plus Wire ® Sidexis XIOS (Sirona Corporation) Cost (kit) $ 12,560 Enhancement tools Fair Warranty 2 years Features: Sensor size # 1 and # 2 Extraoral options Yes -Good sensor comfort -Minimum radiation -Overall grade: 3.1 Sensor Comfort Good Ease to Set-up Excellent Speed Excellent (3 sec) CRA Foundation SIDEXIS Receptor vs. #1 and 2 Dental X-ray Films 40 x 24 37.3 x 22.3 41 x 31 SIDEXIS Receptor vs. #1 and 2 Dental X-ray Films 29.5 x 6 31 x 1.5 24 x 1.5 Lightyear Cost (kit) $ 9,995 Enhancement tools Fair Warranty 5 years Features: Sensor size Extraoral options # 0, # 1 and # 2 -Lowest cost -5 year warranty Yes -Overall grade: 2.8 Sensor Comfort Poor Ease to Set-up Excellent Speed Good (10 sec) CRA Foundation Sigma – Snapshot (Instrumentarium) Cost (kit) $ 11,920 Enhancement tools Excellent Warranty 2 years Features: Sensor size # 1 and # 2 Extraoral options Yes -Good sensor comfort -Sensor can be soaked -Overall grade: 3.6 Sensor Comfort Good Ease to Set-up Excellent Speed Excellent (3 sec) CRA Foundation Dixi ® (Planmeca) Cost (kit) $ 12,661 Enhancement tools Excellent Warranty 2 years Features: Sensor size # 0, # 1 and # 2 -Good sensor comfort -Sensor can be soaked -X-ray head available -Overall grade: 3.6 Extraoral options Yes Sensor Comfort Fair Ease to Set-up Excellent Speed Excellent (3 sec) CRA Foundation Planmeca Dixi ® Receptors Dr. Suni (Suni medical Imaging) Cost (kit) $ 9,661 Enhancement tools Excellent Warranty 1 years Features: Sensor size # 0, # 1 and # 2 -Minimum radiation Extraoral options Yes Sensor Comfort Good Ease to Set-up Excellent Speed Good (8 sec) -Thin sensor -Overall grade: 3.1 CRA Foundation OPTime (Sorodex USA) PSP Cost (kit) $ 11,600 Enhancement tools Excellent Warranty 2 years Features: Sensor size # 0, # 1 # 2 # 3 -Very good image quality -Easy clinical implementation -Single plate scanner -Overall grade: 3.0 Extraoral options Yes Sensor Comfort Good Ease to Set-up Excellent Speed Good (49 seconds) CRA Foundation OPTime Receptor vs. #0 and 2 Dental X-ray Films 35 x 1.6 26 x 1.6 31 x 1.5 22 x 1.5 DenOptix QST (Gendex Imaging) PSP Cost (kit) $ 13,995 Enhancement tools Excellent Warranty 2 years Features: Sensor size # 0, # 1 # 2 # 3 -Very good image quality -Easy clinical implementation -Carrousel scanner -Overall grade: 2.7 Extraoral options Yes Sensor Comfort Good Ease to Set-up Excellent Speed Good (92 seconds) CRA Foundation DenOptix Receptor vs. #1 and 2 Dental X-ray Films 40 x 24 40 x 24 41 x 31 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 1.6 22 x 1.6 31 x 1.5 22 x 1.5 Gendex DenOptix 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 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 Enhancement tools Excellent Warranty 2 years Features: Sensor size # 0, 1, 2, 3, 4 Extraoral options Yes -Very good image quality -Easy clinical implementation -Overall grade: 3.1 Sensor Comfort Fair Ease to Set-up Excellent Speed Good (57 seconds) CRA Foundation DENT-X Scan-A-Ray 500 Intraoral plates on scanning drum 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? So what should I look for...? • 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?