Coming of Age: Digital Imaging Taking Root After Decades of Progress

A: As a diagnostic imaging consultant, I have recently noticed a dramatic increase in the knowledge base of general dentists and clinical specialists regarding imaging technology. Attendees of cone-beam computed tomography (CBCT) courses at the 2015 ADA Annual Meeting in Washington, DC, for example, brought with them excellent questions and knowledgeable interaction compared to even a few years ago. Further, in my opinion, attendees’ knowledge of maxillofacial anatomy also has improved substantially. This indicates that dentists are now more comfortable then heretofore in reading and using multidimensional x-ray images for treatment planning and guidance.

As 2016 progresses, a continued evolution of imaging can be expected, with refinements in digital imaging. Greater reliance on tomosynthesis-corrected panoramic 2-dimensional (2-D) images can be anticipated, and 3-dimensional (3-D) imaging based on CBCT should become more mainstream in clinical practice. Also, visible light imaging will likely grow in use, especially as a replacement for chemical impression materials and for CAD/CAM applications. While tooth crowns will be captured by visible light, roots will be captured via CBCT.

Recently, new position papers have emerged concerning guidelines for use of CBCT, including those produced by the American Academy of Oral and Maxillofacial Radiology (www.aaomr.org, “publications” tab). These include the recently updated position paper on the use of CBCT in endodontics and one on imaging in dental implant planning, as well as a position paper on use of CBCT in orthodontics. Such guidelines are being cited and supported in the clinical literature.¹

For the immediate future, I think clinicians can expect the following trends in imaging technologies in dentistry:

• a dental profession that is better informed, educated, and experienced in appropriate selection and use of digital imaging in dental diagnosis, treatment planning, and image-guided treatment
• greater emphasis on proper selection of appropriate imaging, including imaging wisely for all patients and gently for children
• the availability of lower-dose options when imaging children better understanding of 3-D architecture of the maxillofacial tissues
• a realization that all imaging has potential artifacts and being able to separate these from actual disease
• greater use of multidimensional imaging to aid in diagnosis, treatment planning, and simulation, and interactively for treatment guidance
• detection of more healthcare needs beyond the scope of dentistry, making the dentist evermore connected to the healthcare enterprise in general

Besides a greater use of CBCT, there will also likely be a move towards panoramic dental machines becoming central to dental imaging with tomosynthesis (when available) improving effective beam geometry, and better digital detectors and reconstruction algorithms improving image clarity. As recognition of such improvements, there is now a new 2016 CDT code for posterior dental radiographs of tooth crowns and roots made using specially collimated and projected images via certain panoramic dental x-ray machines.² Additionally, there is an increasing trend towards hybrid systems combining a high-end panoramic dental x-ray machine with a small or medium field-of-view CBCT detector, with a footprint comparable to a panoramic dental x-ray machine alone.

Dr. Levato

A: As clinicians, our treatment responsibility is connected to the medical imaging community, which includes x-ray radiography, magnetic resonance imaging, medical ultrasonography or ultrasound, endoscopy, elastography, tactile imaging, thermography, medical photography, and nuclear medicine functional imaging techniques such as positron emission tomography. While always available by referral, medical radiology is not commonplace in everyday clinical dental practice. However, it is a strong precursor to the future trends that can be expected in imaging applications for dentistry. These trends include:

• ongoing measured technical improvements in all of the modalities currently in place, such as improved sensor resolution, more efficient use of ionizing radiation, faster processing of 3-D images, and growth of multifunctional imaging instruments like laser, visible light, and fluorescence combinations
• significant software enhancements such as image automatic optimization, standardization of image transfer, and open interoperability between all manufacturers of imaging products
• DICOM standards becoming the default file of any clinical image
• the development of similar multimedia enhanced radiology reporting (MERR)³ currently used in medical radiology, which improves understanding of radiology findings by correlating images to text reports
• expansion of ultrasound diagnostic applications in dentistry
• further adoption and implementation of cloud technologies4
• greater centralization of clinical data. This means proprietary data will have to become interoperable to enable collaboration and unification of all clinical data. Vendor neutral archives (VNAs) are available in medical radiology⁵ and should become available in dentistry.
• expansion of the use of telemedicine, which is expected to reach $27 billion globally in 2016.⁶ Moreover, by 2018 two-thirds of interactions between healthcare organizations will be conducted by mobile devices.3 Currently, teledentistry is used predominately as a consultative medium; however, the exponential use of mobile smart devices will provide significant opportunities to enhance communication between dentists and their patients.

Today’s changing healthcare landscape places high demand on improving the quality of patient care and reducing overall costs. Adoption of new technologies such as 3-D imaging, application software, cloud computing, and telemedicine will play a major role in allowing clinicians to master these challenges and improve their ability to better utilize health information through centralization of clinical data.

Dr. Miles

A: Digital imaging has finally come of age in North America. Sadly, it did not happen in the area of radiology with the introduction of intraoral sensors, but with the emergence of cone-beam computed tomography (CBCT), the success of implant dentistry, and, subsequently, the optical scanner. The merging of these technologies made surgical guide production fast, precise, and affordable. Nevertheless, many dentists—especially in the United States—still persist in using film as their image receptor, thus missing out on the exponential growth of implants.

On the bright side, with the emergence of all of these 3-dimensional (3-D) imaging tools, more dentists are looking to enter the world of digital imaging. This world encompasses things like solid-state detectors, intraoral video cameras, optical scanners, 3-D printers, panoramic radiographic machines, and CBCT. Because 2-dimensional (2-D) image receptors like solid-state detectors (sensors) were only necessary for diagnosis and not surgical tasks performed by the dentist, adoption of these conventional 2-D tools has been slow. Many dentists delegate their imaging tasks (including cone-beam imaging) to their staff members and do not place as big a value on imaging as they do on producing restorations, fixed and removable. They don’t seem to understand the rewarding profit margins that can be attained from diagnostic x-ray services. It has taken the maturation of implant technology, now highly dependent on imaging, to move the professional dental needle forward towards a truly digital practice, making the adoption of 3-D products much more rapid.

While the road to digital imaging over the past 25+ years has been long and slow, the future appears to be bright. One can expect the introduction of new cone-beam machines with improved features and image quality. Only a small part of this growth will be due to changes to the machines themselves. The advances will be robust improvements in software and services. Some will come from the machinery manufacturers, who will enhance their software to reduce noise, especially from different restorative materials, and improve image quality. But there will be dramatic improvements in third-party software and the ability to “move” the data from cone-beam scans for producing things like surgical guides for implants and sleep and temporomandibular joint (TMJ) appliances. This will be accomplished by faster and simpler use of DICOM data from CBCT machines to integrate with data from optical scanners, 3-D printers, and other devices.

Additionally, there will be a push towards cloud-based server/software for sharing data between dentists and dental specialists, laboratories, and possibly even payers. Many imaging and workflow tasks will become web-based, with solutions offered to dentists independent of the manufacturer. On a more practical front, dentists will continue to:

• adopt 2-D digital imaging, both intraoral and panoramic
• investigate and purchase CBCT technology
• purchase optical scanners and 3-D printers
• investigate third-party software solutions that are simpler and easier to use
• seek additional training to utilize these devices and understand the technology, especially cone-beam imaging

All of these efforts should lead to easier, more practical solutions to common dental tasks, simpler and more profitable office production, and happier and more successfully treated patients.

Allan G. Farman, BDS, PhD, DSc (Odont)
Independent Consultant
Maxillofacial Imaging Science
Chicago, Illinois

Claudio M. Levato, DDS
Private Practice
Bloomingdale, Illinois

Dale A. Miles, DDS, MS
Private Practice
Fountain Hills, Arizona