What’s Your Wish List?
The options and choices available for imaging in dentistry are varied and complex, and it’s important to begin the decision process by getting a good understanding of what you’re trying to accomplish. While it may sound simplistic, or even laughable to suggest that a professional imagine what their practice would look like if it was “perfect”, this at least gives us somewhere to start the process. Think of the patient’s experience as they come through your practice. Think of the process in the operatory. Think of the discussions between your patients, your staff, and you. Think of your professional life and the other activities which require your time such as courses you teach, lectures you give, and articles you write. Now, imagine how images fit into each of those areas. In some areas they don’t, and in some areas they are key.
Do you need images for publication? For patient education? To help your staff explain procedures? To email to specialists, or to referring dentists? Do you need them for records?
Get Specific about the IMAGES
Now, we understand that we can’t implement a wish list, so begin the process by prioritizing and evaluating. While it’s not always possible to do, it’s sometimes helpful to put dollar figures along with each item that is being seriously considered. For example: if the purchase of a Pan is being considered, we can get a pretty good estimate of the total cost by adding the purchase cost, the installation cost, the training cost, and the ongoing costs. Likewise, we can evaluate the benefit by totaling the predicted Pan revenue. We may also predict a benefit due to our patients perceiving that we are current with technology. Some imaging decisions are based on the assumption that our patient communication will improve and our case acceptance will increase. If that’s the case, make an estimation, and decide how much your case acceptance needs to increase to make it worthwhile.
Not every decision is made solely on the basis of immediate financial return. Patient care, standards of treatment, professional development, and staff education are all obviously important elements of every decision. However, imaging systems can become highly successful or wildly expensive, depending on their implementation, and it’s important to understand your goals early.
Once you have an understanding of what makes sense, and what’s only a “wish”, get specific about exactly what you expect to get OUT of your imaging system. As another example: let’s say that we want to be able to display images on-screen to our patients. We require both intra-oral and “smile” images because we want the hygienists and dentists to be better able to communicate with the patients. From a financial perspective, we predict that case acceptance will increase 10%, our patients will refer more new patients at a rate of 20% more than current, we’ll do 30% more cosmetic work like veneers and bleaching. We’d like the hygienists to be able to display images immediately while the patient is in the chair. We’ll use those images to discuss cleaning issues, and for the dentist to be able to explain routine restorative requirements quickly. Additionally, we’d like the ability to discuss larger cases in the consult room with accompanying images. We’d also like to build a library of images showing our work, for the purposes of patient education.
Once you have a written document that describes the image requirements, you’ll be ready to describe the requirements for getting those images. Where do the images need to be acquired? Who will do that? What type of device will take that type of image?
In our previous example, it would become obvious at this point that the hygiene ops require intra-oral cameras, along with monitors for viewing. We likely don’t need a video printer since our current requirements only demands that the image be displayed onscreen and then disappear. All hygiene ops will be outfitted with cameras since our plan demands that all patients be exposed to the imaging system for us to reach our targets. We also require a camera for capturing images for case presentation, which occurs in the consult room. We need a way to archive and recall those images. Likely a good quality digital camera with a ring flash would be a good choice here. We’d download the images to a computer in the consult room.
It’s important to notice that we started the evaluation by deciding what we wanted to “display.” We didn’t start by deciding we needed 2 intra-oral cameras, 2 monitors, a digital camera, and a computer. Had we started at the other end, we would likely have a very different set of hardware, which would likely not fit our needs as well. If you can clearly define what you want to display, you can get help evaluating what you need to accomplish that.
Whether we’re talking about film-based or digital radiography, intra-oral cameras, digital cameras, microscopes with video or still capture, or even 35mm photography; we can divide image acquisition systems into 4 different categories: stand-alone analog, stand-alone digital, networked analog, and networked digital.
The traditional intra-oral camera cart with the monitor and the video printer is a good example of a stand-alone analog system. A 35mm camera, a video camera and printer on a microscope, or even the traditional radiograph are also all stand-alone analog systems.
These systems all share a few common features and limitations:
– The image is never digitized, and therefore (normally) retains more information and has a “better” image quality.
– The resolution is often higher and the sharpness is better.
– Of course, digital archiving of the images on computer is not possible, and to retain the image either a film or print must be stored.
– The cost of the film and/or prints can become significant.
– The image only exists in one place at a time, unless a physical copy is made.
These systems are normally “turnkey solutions” meaning that there is limited work required to install or integrate them into the office. Imagine adding an intra-oral camera cart, a 35mm camera, or even a Pan to the office. A purchase is made, the product is delivered and it is positioned and/or installed somewhere convenient in the building.
To make use of the device, you either take the patient to it, or move it to the patient. Image acquisition can therefore only occur in one location at a time, unless you purchase more units.
The initial cost of these types of systems is the lowest in a category, but the ongoing costs may be greater (film, time, chemicals, developing, paper, etc.).
These systems are (relatively) simple to operate and simple to maintain.
The simplicity of these systems is due to the fact that they are not very versatile, and perform only a very few functions.
“Integration” into the practice involves nothing more than staff training.
Stand Alone Digital
A computer on a cart with an intra-oral camera, or a digital camera and a single computer are stand-alone digital systems. Schick Technologies (for example) bundles their digital radiography sensors with a Dell Laptop with the Schick software installed. This allows them to provide a “turnkey solution” which allows a practice to begin deriving some of the benefits of digital radiography without requiring a complicated installation and integration in the office. These stand-alone digital systems all share the following characteristics:
– A digital image is produced during the acquisition process.
– This image is stored on a computer, and can be displayed, manipulated, or (usually) printed now or at any time in the future.
– The digital image can be shared with others, and reproduced as many times as required.
– The acquisition system (camera, sensor, computer, etc.) exists in only one place, and must be moved to the patient, or vice versa.
Often, digital systems cost more than a comparable analog system, but not always. This is especially true when ongoing costs like film, developing, and time, are included in the evaluation.
gitization of an image always results in a loss of information. The degradation of the image and the resulting image quality is the subject of great debate. Digital photographs using a good digital camera are certainly good enough for most applications, with the possible exception of publishing. Digital intra-oral camera images are significantly degraded in comparison to their analog counterparts, but are also good enough for most applications. The technology subject to the greatest controversy is digital radiography. Many experts claim that the current “state of the art” in sensor and image plate technology does not produce an image with fine enough resolution to be a viable alternative for traditional film. Others claim that the ability to adjust the image brightness and contrast, along with features like zoom and measurement allow a trained eye to see far more detail in a digital radiograph than they could in an equivalent film based image. This group further suggests that combined with the timesavings, enhanced patient understanding, radiation reduction, and other benefits of the technology, digital radiography is clearly the better alternative. This debate will continue for the next few years, until the technology improves to a point that image quality ceases to be an issue.
These systems are not “integrated” into the rest of the practice, in the sense that they remain disconnected from existing computer and video systems.
These devices are subject to sudden data-loss, since the data exists in a digital format in only one place. It’s important to incorporate some type of backup process with tape, CD, or otherwise.
A practice with several operatories requiring intra-oral cameras throughout is a good candidate for a networked analog system. Traditionally, cameras and/or docking stations are installed in each Op, along with TVs for image display. Cabling runs back to a central location that houses a video switch and video printer. The TVs may also be connected to a central cable TV feed, or DVD, VCR, or satellite, for patient entertainment or education.
The primary reason for a networked analog system is cost savings over an equivalent number of stand-alone systems. Only a single printer is required, rather than one in each OP. Additionally, fewer cameras may be required since the Ops may be wired for cameras or docking stations and the camera brought into the OP only as required.
Significant timesavings result if the image acquisition and display tools are always close at hand, regardless of the OP in use. The savings are reduced if a camera must be moved constantly between rooms, or if staff must take constant trips to retrieve prints.
Better ergonomics and ease of use result from a custom installation with mounted cameras and TVs rather than a simple video cart.
The analog video equipment installed in the operatories is not integrated with any digital systems in the practice, such as practice management software, and is used only for imaging and video.
Images are never digitized, with all the resulting benefits and limitations as described above. The most important limitation is the inability to display an image on screen at a later date, or in another location.
A networked digital system involves digital image capture on computers spread throughout the practice, which are linked back through a network to the central server or servers. Installing computers in the operatories allows for the opportunity to network all of your existing computer and software systems, and to integrate any current and future imaging applications. An image captured in an operatory is instantly available at the front desk, in the doctors’ private office, or in a consult room. Likewise, practice management functions like scheduling or posting treatment can be performed at the computer in an Op.
Networked digital systems offer the greatest versatility, since all the data exists on the same systems and can be manipulated, copied, distributed, and printed using whatever software tools are available in the practice.
The ability to add new functionality to a networked digital system is limited only by the size of the imagination (and a corresponding amount of time and money).
Data is stored on the central server and is normally safer since backup processes occur at a single location and are more carefully monitored. Additionally, a good imaging server will have significant built-in redundancy (RAID, UPS, redundant power) and a more stable operating system than a stand-alone imaging station.
The cost of an integrated imaging network is significant. Up-front costs for hardware, installation and configuration are important, but remember to evaluate the ongoing costs of staff training, ongoing support, and system administration.
The greatest limitation of a networked digital system is the inherent complexity. As the versatility of a system increases, its ease of use decreases. Make sure you have experts to assist with planning, installation, configuration, and training, as well as the inevitable unexpected issues which arise.
The process of specifying exactly what you are trying to accomplish with your imaging system, along with an evaluation of the capabilities and limitations of each of the 4 types of systems, should make your choices clear. If this is still a difficult process, go back to your initial wish list, and your specific requirements, and re-evaluate.
Once you know what type of system you need to implement (analog or digital, stand-alone or networked), you can begin the complicated task of evaluating specific products. This is where you learn about specific cameras or sensors, and about software, printers, monitors, etc. You’ll need to make decisions about vendors, installers and setup (if required), training, and support. While this is never an easy process, knowing what you are trying to accomplish will make it much easier to make these decisions.
Process and Training
Ultimately the successful implementation of any imaging system depends on the team members who will use it. Some practices have spent significant amount to install imaging systems that are almost never used, and others derive real benefits from their imaging investment. The difference normally comes down to two important factors:
An imaging system is only useful if it is actually used. Asking staff to begin performing a new task throughout their already busy day is a difficult thing to do. Often, a practice introduces imaging technology because the dentist understands the need for collecting images, but the rest of the team may not immediately understand that need. Left to the whim of the moment, incorporating image acquisition into the daily routine is a slow process because there is always something else that needs to get done.
A common mistake is to install an intra-oral camera in the hygiene operatory, and ask the hygienist to “start using it when you have time, or when it makes sense.” The fact that the camera becomes an expensive but unused wall ornament should not come as a surprise.
Most practices will need to adopt new processes to ensure that their new imaging systems are used appropriately, or even used at all. That same practice in the example above might make it mandatory that an intra-oral image appears on the monitor before the dentist is called to do their check. Or they may require that every hygiene patient leave with a printout of an intra-oral image. If, on the other hand, they can’t find a good reason for taking the time to use the camera on a regular and routine basis, it’s time to get rid of the camera.
Define a process that explains who is responsible for acquiring images, when this is to happen, and what is to be done with those images. Make it clear and straightforward, and start small. Remember that using new technology is a time-consuming and difficult thing to do. Make the tasks simple and repeatable to avoid frustration and delays. If images are to be taken only during certain cases or procedures, make sure that those situations are clearly defined. Asking a hygieni
st to take a photograph of “anything interesting” is not a clearly defined process.
Once the process helps the staff develop a good understanding of the equipment and the value of the images, you will find that the imaging tools will be used more and the initial resistance will disappear.
Training is obviously very important when any new technology is introduced into the practice. This is especially true for imaging technology since this is often an entirely new experience for many of the staff. Enlist the help of an expert who can help staff develop the skills to
Understand which images to take. There should be a documented regimen for the specific images that are to be taken. Some practices take images only during a “Complete Oral Exam.” Others collect before and after images, or take images throughout larger cases or long procedures. The specific images required will depend on your needs and the reasons for collecting images. An orthodontist and an endodontist may both produce digital reports, but will certainly collect entirely different sets of images.
Know how to acquire images correctly. Working with cameras and sensors requires a steady hand and some new skills. Professional photographers spend a lifetime perfecting their craft. Luckily, dental photography does not involve the varying and unexpected scenarios required of regular photography. Lighting, exposure, f-stop, focus, etc. can normally be controlled and reproduced. Often, an expert will be required to setup your equipment and train staff to take a certain limited set of photographs. Then, the staff’s role is to perform that task over and over with each patient. Carefully document the optimum settings, and know how to produce good images with your equipment. This provides a good base from which to begin experimentation.
Interact well with the patient during image acquisition and while the images are being presented. For example, direct digital radiography sensors (Schick, Sirona, etc.) are somewhat bulky and difficult to place comfortably. Experts explain that the most important new skill to learn while making the transition to this technology is the ability to help the patients get comfortable with the sensors. Communicating correctly with the patient before and during sensor placement is critical. In addition, once a direct digital radiograph has been acquired, it is immediately available for presentation to the patient. For many patients, this will be the first time that they are studying a radiograph. Commonly, it is confusing to a patient that the light areas of the image correspond to the dense areas of bone. By inverting the image (a single click of the mouse using most imaging software) the radiograph becomes more meaningful to the untrained person. It is more intuitive that the dark areas are the dense areas, and it becomes easier to discuss.
Know how to work with the system to collect and store images.
Whether the purpose of the imaging system is to compile an image library for patient education or lectures, or to create records for patients, it is always important that images are collected, named, and archived correctly. Dental imaging packages help to make this straightforward, but staff members need to know how this process works. It’s also important that the backup procedures are documented and carefully followed.
The possibilities for image capture and manipulation in dentistry are varied and ever changing. No two practices are the same, and no two practices use images in the same way. While experts are available to help with the planning, implementation, and training issues that surround your imaging requirements, the most important part of the process is to first evaluate those requirements. By first carefully evaluating your needs, and your future plans for incorporating imaging into your daily routine, you will be able to put together an imaging system that provides a real and tangible benefit to you and your patients.
Further resources to assist with the implementation of imaging systems, including checklists and contact information, can be found at www.compudentinc.com/dpm.htm. Craig Wilson is president of CompuDent Systems Inc., which provides custom computer, networking and technology solutions to dentists and the dental industry.