Transcript Document

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?