While integrating digital dental radiography into the dental practice should not be undertaken lightly, neither should it be approached with apprehension or fear. Digital dental radiography can enable enhanced visual diagnostic acuity by general dentists, specialists, and oral and maxillofacial radiologists. However, properly implementing the technology requires that dental team members receive appropriate, equipment-specific training relevant to their respective roles. Further, ensuring the ongoing safety and efficacy of the technology mandates adherence to infection control, care, and maintenance protocol.
Like other healthcare professions, dentistry is constantly changing to keep up with the newest technological ideas and innovations. As the industry immerses itself more fully in the digital realm, radiographic systems and the information technology infrastructure needed to support them are being updated and reconfigured. There are many reasons for practices to switch to a digital radiography system, including recent regulations and mandates for digital healthcare records, as well as the precision now afforded by nearly flawless and instantaneous imaging.
To a practice that has not yet fully transitioned to digital radiography, the process can seem intimidating, especially to staff members who will now be using unfamiliar technology on a daily basis. Training must be available for the entire dental team at all stages of digital radiography and technology plan implementation, especially during the initial phase. Ideally, with sufficient training and support, hesitation or fears can be minimized.
Fortunately, there are numerous education and training options and opportunities, including those offered by product manufacturers, vendors, dental schools. and professional organizations.
With digital technology, including digital radiography, there will always be new systems, updates, and software, and dental practices should strive to stay current. It is incumbent upon dental professionals to set aside time for training, especially for digital radiography systems. Even if it is just a review of current technology or time for staff to ask questions or be retrained, time should be allocated at least once a year to ensure that all relevant staff members feel confident using the technology. This could occur concurrently with satisfying annual staff continuing education requirements.
According to Jeffery Price, DDS, MS, an oral and maxillofacial radiologist and associate professor of oral maxillofacial radiology from the University of Maryland School of Dentistry, most state boards have established minimum training and continuing education requirements for maintaining licensure for dental radiology proficiency. However, he adds, “As far as digital dental radiography, there’s really not a legal requirement for clinicians to meet, but there’s a professional obligation involved when a dentist decides to go digital.”
Practices considering a particular system may be able to test it prior to purchase to determine if it is appropriate for integration into their current practice setup. This trial run offers the entire dental team the opportunity to ask questions and offer input, which they can also do during initial training by the company after system purchase and installation. Similarly, because questions may arise after the initial training is complete, the vendor should also be willing to return for follow-up questions or even for a short refresher at a later time.
“Front office staff need to be comfortable with computer terms, since they won’t be viewing diagnostic components of digital radiographs; they need to be comfortable handling and saving files to ensure they’re not accidentally deleted,” Price emphasizes. “In the back office, hygienists and assistants will need to become comfortable with certain software operations, such as image adjustments for brightness and contrast, image inversion, colorization, etc.”
In terms of training for 2-dimensional imaging, whether intraoral or panoramic, one focus is positioning the sensor in the right place—aiming the radiographic source at the sensor and perpendicular to the tooth—and putting the patient in the correct position in the panoramic unit, explains Donald Tyndall, DDS, MSPh, an oral and maxillofacial radiologist at the University of North Carolina School of Dentistry. Such training, he says, emphasizes the need for dentists, hygienists, and assistants to learn how to properly align the radiographic beam with the sensor.
After learning to properly adjust the equipment, says Tyndall, “the main training is using the software—whether it’s 2D or 3D— so the sensor is ready to receive the radiation and then images may be manipulated to enhance viewing.”
Roles and Training of the Entire Dental Team
A digital radiography system provides new opportunities and responsibilities for all dental team members. A digital radiography system enables dentists to diagnose patients more effectively and efficiently. This includes the ability to work in a more collaborative way by sharing information more quickly and easily with other practitioners and specialists, including those outside the practice. Digital information transmitted electronically means that conversations and consultations can be conducted promptly—perhaps even chairside—to aid in treatment planning and co-diagnostics with the patient.
Practitioners should be aware of the obligations that come with these conveniences. It is up to them to provide opportunities for other staff members to remain abreast of effective ways to use digital radiographic systems. They should strive to provide an atmosphere in which staff members feel empowered and motivated to learn about and use the new technologies available.
The roles of the dental team members remain relatively unchanged. “The key to proper training, especially with digital radiography, is to have the dentist and clinical staff understand the difference between sensor types, proper sensor placement, and the various types of imaging software—all of which greatly affect obtaining an optimal diagnostic image,” explains Deb Nemes, Western region professional clinical services for Schick. “Digital training involves understanding how to select the correct sensor size to accommodate varying patient mouths, how to adapt sensors to different patient anatomies, how to utilize various types of positioning devices, and, finally, how to program the variety of x-ray generators with the brand of sensor being used.”
It is also the role of the dentist to stay current with new technologies and emerging trends. Ways to remain knowledgeable include reading professional journals and attending continuing education classes. In the case of digital radiography, it is critical to find objective data and unbiased resources to determine the best systems available.
Clinical assistants will likely be using the digital radiography system often. A digital radiography system offers them many benefits, especially the ability to see immediately if images taken will be suitable or if adjustments are needed. As a result of the implementation and training process, staff will begin to understand how digital sensors allow them more clinical time to educate patients using software tools that help increase case acceptance and reduce patient time in the chair.
Finally, although they may not realize the same benefits from a digital radiography system as their clinical staff members, administrative staff may find that a digital system greatly simplifies their work. Digital images allow for instant and seamless information transfer, specifically between offices with DICOM-compliant or otherwise compatible systems. Additionally, because “film copies” of images are eliminated, multiple people can view information at the same time, which is ideal for a busy practice with a large staff. By creating a paperless record, the administrative staff members are able to file insurance claims electronically to expedite reimbursement.
Workflow
Switching to a digital radiography system can improve the practice workflow because digital radiography systems can be integrated into imaging and practice management software, dramatically improving the overall workflow process. Patients can be provided with a faster diagnosis, and dental professionals can spend more time with their patients. The workflow becomes more efficient and effective.
Digital radiography often replaces the need for human effort by completing some simple tasks automatically and leaving time for other, more difficult tasks. For example, a digital radiography system makes it much easier to capture and duplicate images. This leaves more time for procedures such as endodontic therapy and implant placement, which a digital radiography system also simplifies to some degree. In some cases, having a digital radiography system can also allow time for procedures not previously offered.
Digital radiography may also be a boon to time-pressured patients. Because digital information—including radiographs—can be easily shared between practices when DICOM-compliant, patients may not have to make as many trips between a dental practice and a specialist, saving them time.
Rather than requiring patients to wait for information, dental professionals using a digital radiography system have the ability to discuss a diagnosis or treatment plan with a patient immediately. Additionally, with the benefits of enhanced diagnostics, they can feel more confident that the treatment plans they recommend are the best possible. Assessment of the digital images is the sole responsibility of the dentist.
“When the dentist takes a leadership role and maintains the premise that the ultimate concern is the patient’s well-being, implementing new digital technology can be a smooth transition,” Nemes explains. “Setting aside time for proper training by either blocking out a section of time during normal operating hours or on a day off allows the professional trainer the necessary time to familiarize staff with proper sensor placement, calibration of x-ray generators, and imaging software use.”
“Only a dentist—either general practitioner or specialist—can diagnose radiographs. Radiographs are only a part of the diagnostic process and can be open to interpretation,” cautions Jan LeBeau, RDH, BS, chair of dental hygiene at Pacific Dental Services. “A comprehensive diagnosis would include a patient history, patient future, clinical examination, radiographs, and study models, if necessary.”
Interestingly, one of the most misunderstood concepts held by clinicians regarding digital dental radiography is that they will be held even more responsible—or liable—for diagnosing diseases. However, that responsibility is already theirs—that is, they are responsible for using the best technologies available to diagnosis whatever condition the patient presents with. Therefore, it is incumbent upon dentists to ensure that they have the technologies available to do that. However, it is not the general dentist’s goal—or role—to establish a definitive diagnosis in the case of cysts and tumors. That is the role of the oral pathologist and/or the oral and maxillofacial radiologist when a lesion or condition lies beyond standard dental disease, Tyndall says.
“General dentists do not have to provide the definitive diagnosis, but they do need to recognize an abnormality and make a proper referral,” explains Price.
Maintenance
A digital radiography system is an investment, making the need for instituting a maintenance plan for monitoring the condition of all parts of the system—in addition to the entire IT infrastructure of the practice—a great one. This includes establishing and documenting insurance and repair warranty coverage for digital radiography systems, including data, hardware, and software.
“The professional trainer will demonstrate how to care for and maintain the radiography equipment,” Nemes says. “The sensor manufacturer recommends how best to provide care so the dental office can get years of use from its investment.”
According to LeBeau, when investing in digital radiography, it is imperative that the practice work with a company that can provide initial training for all office personnel and ongoing support, as defined in the mutual business agreement or as necessary. Digital dental radiography continues to evolve into better and better imaging with newly developed sensors. These newer sensors often require software upgrades and/or hardware that the manufacturer can define, she advises.
Although not necessarily considered a part of equipment or technology maintenance, most states require dental practices to maintain a radiation safety manual. In conjunction with this, dental offices must designate a radiation safety officer—either the dentist, office manager, or someone else knowledgeable about radiation safety—who will serve as the “go-to” person for safety inspections, radiology training, quality assurance protocol, and yearly internal reviews of the radiation safety manual, Price says. This manual and the radiation safety officer will outline procedures for evaluating exposure settings, filtration systems, x-ray heads, etc.
“You do need a policy manual for using ionizing radiation,” Tyndall concurs. “It’s not only about policy, but about procedures, also. And it should be practice-specific, incorporating who can order radiographs, how often radiographs are to be taken, infection control and maintenance, and other aspects involved with safety.”
Infection Control
A final key component to implementing a digital radiography system is remembering that infection control remains a primary consideration. Ideally, dental practitioners should already be practicing safe standards for infection control, and these standards, such as barriers and disinfectants, can be applicable to digital radiography machines.
However, digital radiography equipment presents new considerations, and it is important to look for practice-specific solutions, not a simple, generic one. For example, while heat sterilization is ideal for sensor positioning devices, it is not appropriate for other materials, such as sensors, which must be covered with fluid-impervious barriers that are changed or cleaned and sterilized between patients.
In general, experts advise that universal infection control procedures be practiced, in particular those recommended by the respective manufacturer. Overall, LeBeau says that infection control for digital radiography doesn’t differ substantially from film radiography. The only major difference would be placing a plastic, disposable sleeve over the sensor. Otherwise, the same infection control protocols would be implemented.
“Care and maintenance of the equipment is the primary responsibility of the practice with the support of the manufacturer,” LeBeau asserts. “Again, be sure to work with a company that provides this type of support.”
Conclusion
With so many advances in digital radiography systems, there are many things to consider when purchasing, implementing, and then training staff to use a new system. Training is vital to successful, efficient, and productive use of information and digital technologies within the dental practice. This inherently requires dental professionals to avail themselves of thorough and ongoing opportunities to maximize their understanding of the state-of-the-art resources incorporated into the practice, as well as the roles and responsibilities of each team member in achieving smooth and seamless operations. The dentist, all staff members, and patients can benefit from a digital radiography system, and properly integrating this technology can help a practice enhance the care it provides to its patients.
