Switching from Traditional to Digital Radiography

Although digital alternatives to traditional film radiography have existed since the 1990s, many practices still have not adopted them. This article asked dental hygienists who have been through the transition process for their thoughts about the changeover and their advice for others who are considering it.

Factors to Consider Before Making the Transition

At an Advisory Board meeting at Foothill College in Los Altos Hills, CA, a representative from Patterson Dental told attendees that despite their Silicon Valley location, only 50% of the local dental practices had gone digital.

Judy Yamamoto, RDH, MS, a dental hygiene instructor at Foothill, acknowledged that she doesn’t have firsthand knowledge of why that is the case. “But I would assume that for solo practitioners, it would probably be the cost.”

“Expense is a big factor,” confirmed Janell Fuller, LDH, who works in a private practice in Fort Wayne, IN, that recently switched to digital. “One must realize the extent of all things needed: computers in every operatory, number of sensors needed (these are expensive and you may have to share with others), sensor holders and a good printer for printing digital images.” In addition, the practice needs to ensure that the digital radiograph program integrates with the overall office software system, Fuller said.

Rafael Rondon, RDH, a regional hygiene mentor for American Dental Partners who mentors and coaches affiliate practices, cited many of the same expenses Fuller did, adding, “If you’re thinking also of a pano machine, that could cost plenty of money.”

Janet Gruber, RDH, MS, the dental hygiene radiology coordinator at Farmingdale State College in New York, also acknowledged that the change to digital is costly, but she believes that thorough analysis may support making the switch.

“Film and chemicals have gotten expensive. When you add up the chemicals, film and carting costs—we haven’t been able to wash solutions down the drain here for many years, so we have carting agencies to dispose of our solutions—I believe it’s costly to use traditional film. People don’t realize it, because they are incremental expenses.”

Another factor is the practice itself, Gruber continued. “I’m finding that many dentists that have been in practice for years don’t want to make the switch at this point because they’re thinking, ‘I’m going to retire in a few years, I’m not going to make that investment of money and experience a learning curve.’”

When Farmingdale changed over to digital 2 years ago, it was part of an overall effort to go paperless. “One of our primary reasons for instituting a digital system was to have everything in the patient’s chart electronically,” Gruber said. “Another primary reason was to expose our students to current technology.”

“Often, we’re looking to upgrade systems in our offices. Our film processors are getting old, et cetera, and that’s an opportune time to go ahead and make the switch. In addition, many institutions and dental offices are looking to proceed with newer technologies to keep current. I also practice in a dental office where we’ve been using digital for several years, and have experienced the many advantages of the digital system there, as well.”

Rondon agreed. “With the transition to paperless charting, it is clear that digital radiographs would meet this need as well as promote interdisciplinary and transdisciplinary treatment. In addition, though the amount of radiation emitted with traditional radiographs is within safety guidelines, it is further decreased with digital x-rays, which will further benefit the patient, both systemically and emotionally.”

Yamamoto said that the reduction in radiation exposure to the client and operator is one of the primary factors a practice decides to upgrade. “Today’s consumer is educated and aware,” she said. “In addition, television shows such these ‘doctor’ shows, explain the risks of radiation. Clients will ask, ‘Why haven’t you gone digital? Because I understand it’s less radiation.’ Therefore, patient expectations could be a driving force as well. Every time a television show explains about radiation safety with the use of a thyroid collar or a lead apron, for the next 2 weeks after that show airs, all our patients ask that question. It’s the educated consumer wanting to be on top of things.”

Brooke Agado, RDH, MS, assistant professor and senior clinic coordinator in the Department of Dental Hygiene at Idaho State University, also identified the amount of radiation to the patient as a factor to keep in mind when considering the switch. “This includes reduced scatter within the dental environment, particularly an open environment or situation where radiation is used more often, such as a school setting,” she said.

“Another reason why we wanted to change over was because of the issues with hazardous waste including the lead foil in the film packet, and the fixer is pretty toxic,” said Yamamoto. “So I think one really great advantage of changing over is to eliminate hazardous waste and think green.” Agado listed a litany of additional factors in favor of the switch, including speed, quality, and transferability of images and ease of retakes. But both the process of making the switch to digital and the use of the new equipment once the switch is made are not without their challenges.

Challenges Associated with the Transition Process

“Initially, it can be overwhelming to learn a new system,” Fuller said. “The skills used for taking the x-rays are the same as before; however, the computer training is what is more challenging at first.

“The practitioner must compare images by looking at the ‘old’ films compared to the digital images,” Fuller said, adding that this requires patience, curiosity, and the willingness to learn new skills. “This may take time out of your schedule so that you are running behind. Sometimes computer challenges arise, and you will need to learn to correct a problem; for example, rotating an x-ray or moving an image from one section of the mount to another.”

“The biggest challenge, as with anything, is change,” said Rondon. “Though the technique involved is rather simple, it is different than how traditional radiographs have been taken and exposed, and that may pose the biggest difficulty. One of the many benefits of digital radiography is that you can view the radiograph immediately and determine if it identifies the area in question. If not, it is possible to quickly retake the image which benefits both the provider and the patient.”

One topic cited by all the dental hygienists interviewed for this article is the need to choose between phosphor plates and digital sensors as the replacement for film.

“They released the charge-coupled device (CCD) sensor system, which currently is primarily wired,” Gruber explained. “I always refer to it as resembling the remote for a car. They’re big and bulky.”

But they have their advantages. “The instant image on the screen with the CCD sensor is wonderful,” Gruber said. “As you’re walking back into the operatory, the image is appearing, and you can determine whether or not you’ve achieved what you were looking for.”

There are other technologies available in addition to the CCD sensor. Photostimulable phosphor (PSP) plates are small, thin sensors that resemble traditional film packets. PSP plates can be reused multiple times; however, they need to be replaced more frequently than wired sensors. These sensors present their own challenges.

“They have to be read by a laser scanner,” Gruber explained. “If you insert the PSP plates out of order, you then have to reposition the films correctly in the mount, on the computer screen. At that point, you’ve already completed your patient; then you’re looking and saying, ‘well gee, I didn’t get back far enough, or my film is cone cut, I need to expose a retake.’ So you need to go back and retake each individual image, and you’ve already completed the series.

“So there is a quote-unquote processing step with the PSP plates rather than an immediate image projected on the screen, as with the CCD sensors. But the advantage with the PSP plates is that they resemble traditional film, so for instance, when you’re working in pedo offices, it’s great, because children can’t tolerate CCD sensors well.”

Another factor dental offices need to consider when choosing between CCD and PSP sensors is the cost. CCD sensors can cost $12,000, whereas the PSP plates are much cheaper—a significant consideration when a large group of people, such as students, are using the system.

“If I were purchasing one in my office, I’m really not sure which I would choose, as they both have pros and cons,” Gruber said. “I have my students use both systems because I want them to be competent using CCDs and the PSP plates when they enter our profession.”

Yamamoto’s office transitioned to plates. “That transition was very easy, because the plates are about the same size as the film,” she said. “We were able to keep the same XCPs, the same film holders; we didn’t have to invest money in changing that over. We could also still maintain the teaching of the parallelism technique. I would say that for the beginning student, the transition to plates is much easier than to sensors.”

Ultimately, the success of any radiography system depends on the images it produces. “As dental hygienists—and I’m speaking from a dental hygiene and a radiology professor perspective—we really look at film positioning as key to whether or not we’ve been successful in obtaining an image,” Gruber said. “So when we are not getting back to those third molar areas, and we’re not getting far enough forward to capture the distals of the premolars, we look at that as being a film of poor quality. When you consider the amount of retakes—what you would look at and say, ‘I’d like to do a retake on that,’ not necessarily that you would take it, but a theoretical retake—our numbers are higher with the CCD sensors than with traditional film.”

Gruber added that, because some offices find it difficult to obtain certain images, they are moving to panoramic film, supplemented with bitewings. “The sensors have gotten a bit smaller, they’re getting a bit thinner,” she noted. “Cropped and rounded edges are making it a bit easier. But because some of the sensors have gotten smaller, they’re not encompassing as much area as we would normally have on a traditional film packet.”

Nancy Miller, RDH, BA, Ultraconcepts owner/coach and clinical advisor for Jameson Management, points out that choosing between sensors and plates is not the only issue: it isn’t always easy to integrate a digital radiography system’s software with practice management software that may already be in place, so selection is an important part of the transition process, too. And in addition to software, hardware and physical files need to be addressed.

“You need to make sure monitors are available in every treatment room and in a convenient place,” Miller said. “Not having previous hard copy radiographs archived or scanned for quick comparison is another challenge—deciding if scanning old radiographs into the system has any value or is a waste of time and storage.”

And while electronic records solve many storage problems, they come with their own set of concerns.

“Securing electronic protected health information (ePHI) is a major issue and concern that needs to be addressed within the dental profession,” said Agado. “The security of saving on a server and transferring digital images is challenging, given the lack of security of the Internet.”

Challenges Once the System Is in Place

Attaining new computer skills is one challenge that practitioners face once the new system is up and running.

“There are numerous software features,” Gruber said. “Once you learn the system and can expose radiographs, it’s great, but I think a challenge that we meet in private practice is that our days are busy treating patients, so there’s not a whole lot of time to explore the software features that exist.

“If you’re working in a different type of atmosphere, you may have time to explore a new software package. I think with hygienists out in the field, they’re saying ‘okay here’s the system—go.’ So you work with it for several weeks, and then you say, ‘Look at that, there’s a magnifying glass.’ They have built in so many positive features that allow us to enhance and manipulate the image, but we don’t always have the time to spend to learn them quickly.”

One answer, Miller said, is training. “Get relevant, practical training, and get every team member proficient in using the system,” she said. “A good trainer would give shortcuts and practical steps to be able to follow after he or she is gone.”

“From whomever you purchase it, they bring a person that comes and trains it at the office level and shows you the techniques and what extra gadgets it has to use after the x-ray has been taken,” Rondon said. “What you could do to eliminate or illuminate a certain area, or create more contrast on one area more than the other so you could show the patient. They bring a person in and give you more or less a half-day type of training. They train the staff, the assistants, the hygienist and also the doctor how to maneuver or manipulate the system.”

After the training, practitioners need time getting up to speed and making the system work for them. Sometimes, it’s the patient who complicates the process.

“Children can sometimes be difficult because of their small mouths,” Fuller said. “One must be confident while taking an image, be creative, and stimulate thought with ‘outside the box’ ideas to succeed. Usual skills may need to be adapted to every individual’s mouth.” On the other hand, as Gruber notes, sometimes it’s a matter of learning to do a familiar task in a new way.

“One of the things I’m trying to work through with my students and continuing education classes, is once you make the transition, finding the film holders and the techniques that work for you to create the best possible image is important,” Gruber said. “For instance, we need to make changes sometimes in our technique to capture the apices of the teeth. When we work with traditional films in the maxillary posteriors, the film bends a little bit at the apex if the palate is shallow, but we are usually able to get the apices appearing on the film. With CCDs, the sensor won’t bend at the apex. Instead, the whole CCD sensor bends backward with the film holder, so when you place your position indicating device (PID) up against your ring, what you’re ending up with is an image with missing apices because the film is not lying parallel to the teeth. We’ve been working with the students to recognize patients’ anatomical limitations, and increasing, let’s say, vertical angulation in posterior areas to make sure that we’re capturing the apices of teeth.

“At this point, we need an understanding and better visualization of the bisecting angle technique to compensate for some of the limitations that we’re encountering, being that CCD sensors are bulky and not pliable.”

Not to mention somewhat fragile. “It seems that most times when the sensor is no longer functioning, it’s because the wires have been crimped,” Gruber said. “They get bent when not hung or keep outstretched — we have hangers on the wall at the college so the wires are always loosely hanging, to prevent damage.”

“In my office, we have six treatment rooms, and we have three sensors,” Gruber continued. “Smaller offices may have one sensor per room, but I don’t think that many offices with six operatories are purchasing six sensors. In my office, we often have three hygienists working at a time, so the sensors tend to stay in the hygiene rooms. When the dentist sees the patient for an emergency or a new patient that requires radiographs, they move the sensor to their operatory.

“The negative, they say, to moving them around is that breakage becomes more of an issue — the longevity of the sensor may be lessened. We don’t move our sensors at the college. In private practice, breakage is not a major issue, but sensors are expensive when they do break.”

Fuller added that sharing sensors may mean modifying your schedule. “X-rays may need to be taken in the middle or at the end of the appointment,” she said. “All of this can take time out of one’s schedule and the hygienist may run behind schedule.”

CCD sensors may be more fragile and expensive, but PSP plates require care, too. “Reusable plate sensors become worn, showing scratches that distort the image,” Agado said, adding that this sometimes creates the need for retakes.

Benefits of Making the Transition

With all the caveats and considerations, there is a many-faceted upside to digital radiography. Fuller and Miller cite the clarity of the digital images and the ability to obtain them immediately, without needing to leave the patient to develop the film. Furthermore, the images can be digitally enhanced based on the practitioner’s needs. “Images can be enlarged, lightened, darkened and even colored to make examination easier,” Fuller said.

“They all have the ability to invert grayscale, they all have the ability to change contrast and change density,” said Gruber. “You can write on the films — it’s great for patient education because you can circle things; you can even put notes in on a film.

“So let’s say that you see something like an incipient carious lesion on the distal of 19. With some software packages, you can enter a note with a marker on the film. When you click on it months from now, it comes up saying, ‘watch distal 19, incipient carious lesion.’ Or the dentist sees that patient after you do, and that note is already logged on the film.

“Software tools are important, and I use them when grading students. I review the basics with them, and tell them, make sure that when you’re looking for caries and pathology, that you’re changing the contrast and density, because pathology will become more evident as you manipulate the films. The manipulation of films is very important for proper diagnosis.”

“Even though some practitioners believe they can’t easily diagnose pathology when viewing a digital radiograph, for most of us that have been working with it for a while, it’s just what you get accustomed to. When we first made that transition at school, I thought, ‘wow, I’ve really got to think about what I’m looking at.’ Before, carious lesions and periapical changes sort of jumped out at you. Then, once you start working with the digital, they jump out at you again. So I think it’s just a matter of getting accustomed to a different type of image.”

And Gruber is enthusiastic about the software tools. “With traditional films, if you can’t see it, you can’t see it. Other than putting your glasses on and getting closer to it, there’s not much more you can do.”

“The image that digital radiography provides compared to traditional x-rays is amazing,” Rondon said. “Digital imaging allows the provider to enhance local areas of the film to educate the patient on the necessity of treatment and/or identify lesions that may otherwise have been difficult to detect. Digital x-rays allow you to highlight, contrast, zoom in, etc., which is a clear advantage to traditional x-rays.

“It’s huge. When it comes to patient care, I think it speaks for itself, so the patient acceptance of treatment is more likely to happen. We’re talking about, percentagewise, an increase of acceptance up to even more than 50%. It’s huge.”

“I think it takes time to appreciate the difference between a digital image and a processed film,” added Yamamoto. “Computer flat screen monitors are right there at the cubicle, rather than the small lightbox that is usually mounted on the wall too far away. When you have the radiographic image on the monitor, you can enlarge the image for greater detail, you can highlight or change the contrast. When you are explaining instructions or a disease process to the patient, it’s so much easier for them to engage in: ‘Oh, that’s an image of me — that’s the problem with me.’ There’s more interaction that’s created. I think that’s an excellent educational tool for the patients to learn about what their situation is.”

Agado, Fuller, Gruber and Miller all pointed out the digital nature of the images makes it easy to access and share them over several workstations. Not only does it save time pulling the physical charts to look at the images, it saves on postage costs because the images can be emailed to other healthcare providers, insurance companies, and the patients themselves.

“I think that infection control is maintained much better, too, because you don’t have the darkroom,” Yamamoto noted.

“It’s nice not needing a darkroom and not having to change solutions for the processor. The area can now be used for storage,” Fuller said.

Gruber agreed that for new offices, not having to worry about building in a darkroom is a positive. “I know a lot of dental schools are no longer using traditional films, so I’m sure when those dentists graduate, they will all be digital, there will be no more darkrooms.”

“The PSP plates are similar to F-speed film as far as impulses go,” Gruber said. “With the CCD sensors, impulses drop even a little bit more from F-speed film and PSP plates; they drop down an additional 10% to 20 %. Digital radiography is key for reducing patient exposure, with the CCD sensor being the best. I’d say that that’s one of the important benefits, because we’re always concerned about reducing exposure levels and following the ALARA concept.

“My students just love me — I make them use a rectangular collimator in addition to using a digital CCD sensor. Rectangular collimation cuts radiation dosage by an additional 66%, so my patients are truly getting the best of both worlds. My students, however, are faced with technique evaluations with many cone cuts!”

Roles of the Dental Hygienist in the Transition

Gruber and Miller agree that the dental hygienist has an important role in the researching and planning stages of the transition from film to digital. According to Gruber, the hygienist should help decide whether to select a system that uses sensors or plates.

“They need to explore both,” she advised. And I believe system selection should be based on the types of patients being treated, the elderly and children versus the general population. After they determine what kind of system they’re going to institute, they need to explore the software packages that are available, as well.”

“The dental hygienist initiates the process to the patient,” Fuller said. “He or she must explain to the patient the benefits and process. The dental hygienist must be fully versed in taking films and show confidence in his or her film-taking ability and computer skills to make the process move smoothly.”

“The dental hygienist has a key role because they are often the primary ones using the sensors, and need to be comfortable with what they choose,” Gruber said.

In addition, the fact that many dental hygienists work in multiple offices may make them a source of useful information if one practice has implemented a digital system and another is planning to implement one.

“I also believe the dental hygienist is going to be the one to determine the type of film holders used,” Gruber said. “They’re continually releasing new film holders, and hygienists are actually creating many of them, which is wonderful. One of the issues I see is that offices purchase one type of film holder, and if you’re not comfortable with it, you don’t know what else is available. So I believe the role of the dental hygienist is also to explore different ways to be able to create that image that’s free from distortion and free from technique issues.”

Miller said that the dental hygienist can be instrumental in developing shortcuts in the software, and in educating patients as to the benefits of digital radiography.

“Educating the patients regarding the cost and benefits, particularly for patients who regularly decline radiographs,” is a key role for dental hygienists, Agado said.

“So is educating the staff on proper HIPAA compliance and use of digital images, including avoiding the overuse/too many retakes.”

Words of Advice for Practices Considering the Switch

“Do it!” said Agado.

“Hurry up and do it,” said Rondon.

“The sooner the better,” added Yamamoto. “If you are not computer savvy, ask for inservice help and training from the company. Ask them to tailor the software to your specific needs.”

“If you can receive some technical help with making new templates and moving from screen to image, it is worthwhile. The beauty of having an intraoral photo, periodontal charting, and an xray image pulled up at the same time will be really, really valuable.”

“There will be a learning curve,” Agado acknowledged, “but the company reps or other experts/consultants will make the transition easier. My only regret is that we are not utilizing our dental software program to its fullest potential. Utilizing some aspects while also keeping paper records creates double the paperwork. I feel it should be all or none.

“Our biggest challenge with implementing digital was creating and implementing a policy/procedure for retaking, saving, and sending images in accordance with HIPAA law and securing patient information. Hire a HIPAA expert to ensure the proper storage and transferring of electronic protected health information (ePHI) abides by the law.”

“Switching to digital radiography is a tough transition at first,” Fuller said. “Be patient and open-minded. In the long run, using digital radiography is easier, has much better quality of image, and is safer for the patient.

“I would suggest when an office is transitioning to digital radiography that training be done at the beginning of the week. See patients the next day. It is much easier to use the information you learned the next day rather than waiting over the weekend.”

“Although the trend today is to go chartless, I believe it is more prudent to go less paperless,” said Miller. “I think it is a waste of time to scan old radiographs and documents into the digital record. Keep your current patient paper records accessible to reference if needed quickly, and weed out unnecessary paper from the folders. From a set date forward, scan in all new paper documents and do all data entry in the computer record. After a year, you should have the current radiographs for every patient in the digital record along with all of their other current data.”

Miller also advises including the whole team in the decision to change over from traditional to digital radiography.

“Make it mandatory for every team member to be at training, including doctors and business team,” she said. “Set a cut-off date for the old system, and force the team to transition and learn by experience and trial and error. Develop ‘cheat sheets’ for the steps so team members can readily reference them on the fly without having to search for another team member to help them.

“Our transition was pretty smooth. Patient response is the sensor is more comfortable, and they think we are really techno savvy, which makes us feel we are delivering the best service for them and us.”

“It’s moving up in technology, and the patients are seeing a dental practice that is moving up, not staying behind when it comes to things like this,” Rondon said.

“We already feel behind,” Yamamoto said. “Here we are, switching to plates and imaging has now gone to 3D cone beam — the technology is really pushing dentistry forward. Better diagnostics will create better treatment outcomes. It’s exciting.”

Conclusion

“Yes, it’s going to be somewhat challenging,” said Rondon. “But really, overall, it is an awesome technology that has been developed to be able to get more information for the patient and the provider and thereby creating a win/win scenario for all.

“Dentistry is an altruistic profession. It’s all about the patient and trying to provide the highest standard of care. Digital x-rays get us one step closer to that goal.”

“I’ve been thrilled with our digital systems, and I definitely think it’s the way to go,” said Gruber. “I tell my students that, from the literature I’ve read, and from what I can see as a practitioner and working with them for years, if I divided the class in two and gave everybody the same films, some traditional and some digital, they’d all come up with the same answers as to what they were observing radiographically.”

“I believe that to be successful in making the digital transition, practitioners need to be receptive to technology,” Gruber said. “And technology is fabulous.”