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Profile in Oral Health Trisha E. O'Hehir, RDH, BS Editorial Director, Hygienetown Magazine

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Linda Douglas, RDH, holds a Suni digital radiography sensor. Sensor courtesy of Suni Medical Imaging, Inc.

From X-rays to digital radiography – radiographs have certainly come a long way.
What will the next generation of this technology look like and how will it affect you?

by Trisha E. O'Hehir, RDH, BS, Editorial Director, Hygienetown Magazine

Before radiographs, we had simple drawings. Then in the mid 1800s, photographs were used to document lesions and anatomy. The discovery of X-ray occurred on November 8, 1895, by Wilhelm Conrad Röntgen, and on January 12, 1896, in Germany the first dental radiograph was taken by Dr. Otto Walkoff who was both a dentist and a patient. The exposure time was 25 minutes and the quality was certainly not what we see today, what with the major advancements we've made since.

That same year, Eastman roll film was made available for dental X-rays in the United States. In 1913, Kodak produced the first pre-packaged dental X-ray film with two pieces of photographic film in each packet. By 1919, Kodak produced true dental X-ray film. Each packet contained a thin sheet of lead to reduce backsplatter radiation from reaching the film. Increased film speed over the years reduced the level of radiation needed. By 2000, it was 1/60 of the radiation required in 1919.

Digitization of radiographs was introduced by Dr. Richard Webber at the National Institute for Dental Research in 1982 when he introduced subtraction radiography or the comparison of two radiographs recorded with controlled projection angles and thereafter digitally subtracted to determine a difference in bone levels over time. This is particularly useful when evaluating the effects of guided bone regeneration procedures in periodontal clinical trials and for evaluation of caries lesion progression.

The first demonstration of a direct digital radiography system in dentistry was in 1987 in Geneva at the first European Congress of Dental and Maxillofacial Radiology. Dr. Francis Mouyen, a French dentist and inventor made the presentation. It was called RadioVisioGraphy and was produced by Trophy Radiologie, now a part of Kodak. Dr. Mouyen published his seminal paper describing this technology in 1989, which ushered in the age of digital radiography.

The first digital radiographs were viewed on a black-and-white, TV-quality standalone monitor. With the introduction of S-VGA graphic cards, digital images were displayed on a computer monitor. As the price of computers came down, digital radiography became more affordable for general dental practices. Today a variety of software programs are available linking sensors to computers and enhancing image evaluation.

The first phosphor system, Digora, was launched in 1994, based on well known medical radiography technology. The storage phosphor plates look like X-ray film and must be placed in a scanner after exposure to be converted to digital images. Clinicians find the transition to phosphor plates easier than with digital sensors, due to the similarity to X-ray film. Diagnostic accuracy is similar between digital receptors and film.

Some dental offices have made the transition to digital radiography, but many more continue to use film and some practices use both digital and film. Film is still considered the "gold standard," yet diagnostic accuracy is comparable between digital receptors and film. It still comes down to the interpretation made by the human observer when viewing the radiographic images that is most critical. Despite the many advances we see in digital imaging receptors and displays, a wide variation in diagnosis exists among clinicians, particularly for caries diagnosis. Ideally, automated detection systems should be developed to provide highly reproducible and accurate diagnosis for the clinician. In the early 1980s, Dr. Nigel Pitts published several studies showing promising results that computer analysis was as accurate as human observers for the detection of caries lesions. Researchers continue to develop diagnostic programs that match human observations, but none of these are as yet available for clinical practice. Computer-based decision support programs will be available in the future, similar to those now used in medicine for ECG analysis.

Townies Transitioning to Digital Radiography
Nearly half of Hygiene Townies responding to a 2007 poll on radiography reported use of digital radiography. Corded sensors were used more often than phosphor plates or cordless sensors at that time. More so than image quality or the desire for cordless sensors, Townies expressed interest in better compatibility with practice management software programs.

The transition from film to digital requires change on the part of the hygienist, but the rewards far outweigh the transition trauma. Digital radiographs require less radiation for the patient and are faster from start to finish for the clinician. Immediate images are a great way to educate patients and the enhancing capabilities of the software programs available today are easy to use and provide so much more information than traditional films.

Aside from problems with sensor size and placement, especially in children under 10 years of age, Hygiene Townies are enjoying the switch to digital radiography. Townie Pamela-RDH puts it this way: "I love digital X-ray and I think it's very simple. I thought it was more time consuming at first, but now I realize that traditional X-ray took more time after exposing them and digital takes a little more time prior to exposing. It would be really hard to return to traditional films."

On March 21, 2009, "KeriRDH" posted this comment: "I love using digital X-rays. I have used numerous brands: Dexis, Schick, and two kinds of phosphor plates, ScanX and one other brand. My personal favorite is Dexis. The pros are the sensors do not break easily, the software is user-friendly, the Clearvu application is very helpful in detecting caries, generally as comfortable as X-rays can be for most patients. After the learning curve, you can take perfect X-rays in very little time. Some cons include the holders take a little while to get use to using. The sensor needs to be wiped by a special disinfectant. The thickness of the sensor is hard to use on any patient with an excessive amounts of tori. Overall, I have found Dexis to be the best digital system out of the five I have used."

On the same day, in the same message board, Townie "aer" posted: "We like Schick in our office. We have a regular size sensor and a pedo sensor. We have been using this system for more than two years now and still love it. I like how I can move the adhesive BW tab to capture the correct anatomy of teeth/bone."

Townies "coloradordh" and "skr RDH" both use the Planmeca Panoramic and find the BWX that are actually two segments of a panoramic view are great for those patients that can't tolerate sensors or film. The quality of panoramic images for caries detection are not as good as intraoral BWX.

Several Townies prefer the ScanX phosphor plates, especially for patients with large tori. Townie "joy2th" says, " I just love the fact that there is no learning curve with the ScanX, except [when it comes to] the software, and it is no different intraorally with placement and comfort for the patients. Those bulky sensors are just so uncomfortable for the patients! I sweat bullets when temping in an office with them!

Tips From Townies
The digital sensors are a bit bigger than the actual image size, so Townies have asked for help getting the teeth they need on the image. Townie "Msimon" has a suggestion to avoid the problem of cutting off the distal of cuspids on the BWs. For the more anterior bitewing, she angles it so it goes from one side of the mouth to the other, so the most anterior edge of the sensor is practically touching the cuspid on the opposite side of the mouth with the tongue behind the sensor. She then angles the X-ray tube through the cuspid area. According to "Msimon," "It seems like it would be too far forward, but it works."

Townie Sarah Cottingham reminds us that when taking BWs with corded sensors, the "cord always goes to the roof of the mouth."

When "RDH1982" heard a presentation on going digital she was impressed, especially with the phosphor plates versus sensors and cords. She asked other Townies what their experiences were and what were the pros and cons of different systems. Townie "skr RDH" posted a very thoughtful response covering the topic in detail:

Phosphor Plates
Pros: Ease of placement. They are flexible and use film holders, thus less learning curve for placement. Faster than film. At least there is no sorting and mounting like with film. Show the patient right away if you have PC in the op. On the other hand, you need only one PC to get started. Can use large plates in the film-type pan-X-ray – no need to buy a digital pan.

Cons: Time consuming compared to sensors since they require the extra step in running to the scanner, cleaning, unwrapping and being sure they are in the right order and alignment. This is the deal killer for more offices going digital, including our own. Scratches – some say they have to throw out their plates after a dozen to a few dozen exposures.

Digital Sensors
Pros: Instant results seconds after you send in the rays. Fast fast fast – more time saved for assessment, treatment, OHI. If you need to re-align, you can quickly retake in a few seconds after the first image appears. The software typically will allow you to follow a preset series of radiograph 'mounts' so you get a nicely mounted series automatically. Like any digital, you get large images and close-ups that are good for some OHI, you don't have to worry about losing X-rays or go fishing for them in the overstuffed chart folder.

Cons: Learning curve in placing the sensors can be steep at first. Need a whole new set of sensor holders. Patient discomfort is worse than with plates or film. Wire tends to open the bite, so you get less periodontal tissue shown (e.g. bone). Susceptible to being bitten and ruined, with expensive replacement fees. Need PC in every op. Image quality is a controversial issue – it can be fuzzy/poor if not set up correctly, and even still the image is different than film, requiring a different interpretation method. Research says it produces an image of equal diagnostic quality to film. Works better with newer DC X-ray heads. Extra expense. Expensive to get a digital pan-X-ray compared to film.

The world is going digital and so are dental offices – especially new offices. The transition is underway and only time will tell when all dental offices have digital radiography. Hygienists have an advantage over dentists in this area, since many work in more than one office and therefore have the opportunity to use various brands and types of digital radiography. In the words of Townie "RDH83" of her experience with the transition to digital in 2006, "What a trip! It's the most fun I've had in hygiene in 23 years."
Dentaltown Magazine
September 2025
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