The dental practice environment can be filled with a myriad of gadgets and technologies and utilising them appropriately can be a feat in itself. One apparatus that we all expect dental practices to have is the provision to take intraoral radiographs when necessary. Radiographs can be helpful in detection, diagnosis and treatment planning as well as patient communication and record keeping to name a few, and it is here that in the last two decades digital radiography has become more prevalent. In an ideal world all our radiographs would be taken with correctly angled and aligned tubes; in a patient that can tolerate correct film positioning, they would be perfectly developed showing excellent contrast using shades of grey. However in the real world this is not always the case. I remember when I first started practising dentistry over 20 years ago, we developed films by hand in dark rooms with messy chemicals. This was improved with automatic processors that gave us more consistent results. And, although a correctly exposed and processed film may offer advantages over digital plates in early caries detection, they nevertheless still have drawbacks in a busy practice.
The advent of digital radiography has helped to improve our workflow. It has several advantages including:
The taking of radiographs must always be thought of as carrying some risk, and as such have to be justified. This at times can lead a clinician not to take radiographs in children. Guidelines are available (from the FGDP) to help dentists deciding to advise a patient when intraoral radiographs, especially bitewings, may be beneficial. They have to be taken according to dental risk and not by an arbitrary time interval. However, studies show that radiographs can have a net positive yield when detecting oral disease.
At Hafren House Dental Practice we have used several digital X-ray scanners, including direct imaging plates that are placed directly in the patient’s mouth with the advantage of not needing to put them through a separate scanner. These have the slight advantage of a faster processing time, albeit by a few seconds, but can be more cumbersome than the indirect imaging plates and can also present added inconvenience to the operator when needing to use differing plate sizes. Patients may also find them more uncomfortable (due to their sensor thickness) to hold in the correct position (Figure 1). This can lead to retakes being necessary with the ensuant additional radiation exposure. Indirect imaging plates, such as those with the PSPix 2 X-ray system from Acteon, have the advantage of being thinner and possibly more comfortable (Figure 2). We currently use the PSPix 2 by Acteon as our digital X-ray scanner. This uses imaging plates that are constructed using phosphorescent particles sandwiched between a protective layer and polyester support.
Figure 1: Direct size two sensor
Figure 2: Indirect size two PSPix 2 sensor
Although these digital systems can have networking capability so that several surgeries are able to use the same imaging plate scanner in a practice, we actually have one PSPix 2 in each surgery to help our workflow. This saves time by not requiring the dental assistant to go to a different room to place the imaging plate into the scanning unit. The PSPix 2 units are very easy to use, compact, and neat looking, and fit seamlessly into our operatories (Figure 3). Cross infection protocols need to be adhered to during use and protective barrier sheaths, together with the protective card, stop the sensor from flexing too much and helps maintain good infection control. The viewing of digital images is enhanced when they are seen on medical grade monitors. These monitors that optimise brightness and permit small changes in colour to be distinguished better (Figure 4).
Easy integration with existing practice software aids our workflow, as well as the ability to place radiographic images in patient records with allotted teeth notation. This can be very useful when retrieving records for perusal and comparison. The Sopro Imaging software that we currently use at Hafren House Dental Practice really does enable us to keep contemporaneous records. We are able to place clinical pictures taken with either a DSLR camera or intraoral camera, with tooth notation, any comments, and associated radiographs all together for quick access. This becomes very useful when we need to construct referral letters or for patient communication (Figure 5).
Patients presenting to the practice will have differing tolerances to having films or imaging plates placed in their mouths. Strong tongue posturing, gag reflexes, arch shape, adult or child etc, will all mean that one film size will not be adequate to take the different types of intraoral X-rays required. We have different image plate sizes available in all our surgeries and this is essential (Figure 6). Here, indirect sensors have an advantage over direct sensors in that no changing of cable input into a computer or adapter slot is required. The PSPix 2 automatically detects the imaging plate size and there is no need to insert differing size adapters before offering the plate into the unit (Figure 7).
Taking radiographs in children can pose difficulties with small mouths and limited patient cooperation being factors. For some dentists, the taking of radiographs in children can be difficult to justify. Here guidelines from established bodies such as the Faculty of General Dental Practitioners (FGDP UK) can help. Using the appropriate size sensors in small mouths can increase the diagnostic quality and reduce the need for retakes. The taking of X-rays in children for our practice can really help us in not only detecting undiagnosed disease (Figure 8), but also treatment planning, especially if we are thinking of using a biological approach to treat carious lesions.
The ability to use a size 0 imaging plate allows us to take bitewing radiographs in cases where larger film sizes are just not tolerated by a patient (Figure 9). The use of digital intraoral radiography can positively aid a practice to deliver high quality care, and such technologies are constantly being improved. Integrating these in a busy dental practice can have its problems as clinicians do not like change and siting equipment can be difficult, but with modern digital X-ray scanners like the PSPix 2, manufacturers are now making technologies that really can fit very well into our busy working day.
Figures 8a and 8b: Clinically undetected interproximal lesions, but now visible on bitewing radiographs taken with size one PSPix imaging plate)
Figure 9: Bitewings taken with size 0 imaging plate Figure 6 Figure 7 Figure 8a Figure 9a Figure 8b Figure 9b
*This article was originally published in Dentistry magazine