The modern dental practice continues to evolve at a raid
pace. Systems that were primarily paper and film based are quickly turning
towards digital solutions that allow the practice to be more efficient and
effective. The area of the most rapid changes in the past few years has been
digital imaging. While digital radiography has received the lion’s share of the
press recently, digital cameras and intraoral cameras are still, in my opinion,
the biggest bang-for-the-buck in terms of return on investment. For a
relatively small investment, dentists have a method where they can educate
their patients on their existing conditions, communicate with labs, document
cases for insurance purposes, and track patients’ progress. In this article,
we’ll review the criteria for choosing camera systems, and more importantly,
digital imaging software.
It All Starts With
Software
It’s been my experience that while offices spend a lot of
time looking at the criteria of their hardware, far too little time is spent
evaluating the software. However, the software is the more important component!
It will determine which digital systems are compatible, how the software
interfaces with the practice management program, and your day-to-day experience
with the digital systems.
Almost all digital systems come with their own software that
allows capture and basic manipulation of the images. While this software is
adequate for some offices, it is often under featured in its ability to perform
more advanced tasks, such as applying filters to sharpen or improve the
contrast, emailing images directly from the program without the need to
cut-and-paste, and incorporating images directly into Word documents with a
single click. Also, most of these programs are free-standing and do not
directly bridge to practice management software. This is important because most
dentists want to link the images to their patient data without needing to
re-type the patient info when taking images. Enter image management software.
Image management software is designed to serve a number of functions. It allows
an easy method of taking, organizing, and manipulating images. By bridging to
the patient record, it permits data to be exchanged without re-typing. And it
will act as a central database for all images, including digital-x-rays,
intraoral camera images, digital cameras, and scanned photos, slides, and
documents.
To Bundle or Not
Probably the most difficult decision that the dentist faces is whether to
purchase image management software that is sold by the practice management
software company, or to invest in a third-party product. Both have their pros
and cons.
Most of the major PMS companies have incorporated imaging suites into their
offerings. On the plus side, these programs are tightly integrated with the PMS
software; the dentist will feel that they are still in the same program even
though the databases are usually separate. This is actually preferred. With the
constant consolidation that is occurring in the dental technology field, it makes
sense to have image stored in a separate database in case the dentist chooses
to switch to another program at some point in the future. Also, with the
complexity of these various packages, it’s comforting to have the same company
responsible for all aspects of the software. In a few cases, it is possible to
have the patient chart and thumbnail-sized images all on the same screen; this
is not possible when using a third-party program. Also, since three major
companies currently dominate the market, dentists can be relatively secure that
the company will not go out of business or stop supporting their software.
However, this option may not always be the best. In most cases, the image
software is significantly more costly than the third-party programs. Many of
the image programs sold by the PMS programs are modular: a dentist would have
to purchase separate modules in order to be able to images from digital
radiography, intraoral cameras, digital cameras, and scanners. The cost of the
fully-loaded image suite from the PMS company is often more than the PMS
program itself! Another concern is that some programs will only capture images
in a proprietary format, requiring time-consuming conversion utilities if
standardized format, such as JPEG, are needed. The compatibility of the
software with digital systems is more limited with the PMS systems.. Finally,
some of the image suites from the major vendors use a word processor that is
unique to that software rather than being able to work with Microsoft Word.
Are IntraOral
Cameras Still Viable?
In a word, yes. The biggest competition to intraoral cameras
has been the plummeting cost of extraoral digital cameras. A complete extraoral
system from a dental-specific vendor like PhotoMed can be found for
$1600-$1800, well below the cost of a high-end intraoral camera. The image
quality of these extraoral cameras is typically far better than any intraoral
camera; resolution is higher and the shutter speed is quite a bit faster.
However, the main advantage of the intraoral camera is ease of use and time to
see image. With an intraoral camera, you can have an image on the screen a few
seconds after picking up the handpiece. With digital extraoral cameras, you
need to turn on the camera, use retractors and/or mirrors, frame the shot, take
the picture, and then download the image into your software. Hygienists and
staff usually prefer the intraoral cameras because of this. I do feel that both
systems are a great addition to any practice, as each has their own ideal
clinical application.
Fiber Optic
The first and still most popular camera systems on the
market were the fiber optic systems. These systems typically use very high-end
optical systems to produce the best image quality possible. The light source is
in a separate “box” and there is a fiber optic cable from the box to the
handpiece. Until very recently, these were the only type of intraoral camera
systems available. While the image quality is above average to excellent in
most camera systems, there are a few reasons why some offices didn’t find these
cameras to be a good fit for them. The camera and light source are quite heavy
and are difficult to move from operatory to operatory. Some of the original
camera systems were so heavy that a cart that contained all the components
(camera, light source, monitor, and printer) was suggested as the best way to
handle this issue. As any dentist knows, though, when the camera isn’t a few
inches from your finger when you want to use it, it’s not going to be used as
much as it should be used. One of the solutions offered was to put a docking
station in each operatory. While this made carrying the camera much easier, it
added on around $1000-$1500 per operatory to the overall cost.
USB Cameras
Because of the challenges of moving fiber optic cameras, a
number of manufacturers in the past few years have developed USB camera
systems. These cameras are typically very lightweight and unlike the fiber
optic systems, the light source is built into the handpiece, usually a ring of
lights around the lens. This allows the camera to be extremely portable and can
easily be moved from room to room. Since they use standard USB connections,
they can be attached to any computer easily.
However, like all systems, there are pros and cons. Because
of the small size of the lens and the LED lights that are used, many people do
not find the image quality of these cameras to be ideal, especially for
diagnostic use such as locating a fracture or canals for endo procedures. While
many find the image to be acceptable, offices who are accustomed to the quality
of the fiber optic system are often disappointed. Also, since all USB devices
require a small piece of software called a driver to be recognized, the USB
cameras will only work with specific software programs. You’ll need to check
with your image software vendor to determine which cameras are compatible.
Dentists should be aware that there are different types of
intraoral camera systems available and should see the cameras in use before
deciding if a camera meets their requirements for image quality, cost,
portability, and ease of use.
Digital Cameras
In some situations, however, the intraoral camera is not the
ideal choice. While images from a good intraoral camera can be diagnostic, they
are often not adequate for cosmetic imaging cases, communication with labs, or
for documenting certain situations. In these scenarios, an extraoral (digital)
camera would be a better choice. While they were, at one time, more expensive
than intraoral cameras, a good extraoral camera can now be found for about one
half the price of the better intraoral systems.
While intraoral cameras have many benefits, there have always been some
roadblocks for dentists who wished to use them in the office. There is a
learning curve associated with their use; most have a mirror image and so using
them is similar to using a mirror in the mouth. The earlier units had a
tendency to fog up, and you need to use a disposable sheath between every
patient. The units also tend to still be on the expensive side, and better
models still sell in the $5,000-$6,000 range for the basic system. What most
dentists wanted was a way to use cameras that they are already familiar with,
which is the extraoral camera. The problem, for a long time, was the unavailability
of digital cameras. While there are many ways to get traditional photos into a
digital format (more on that later), it is still much more desirable and easy
to have digital images from the start.
When the first digital cameras for consumer use were introduced, they were very
expensive and while suitable for the home, they did not meet the criteria for
producing diagnostic dental photographs. The first units that came out were 1.3
megapixel cameras. Since then, we have seen 2.1 megapixel units, 3.3 megapixel
units, and lately, 5, 6, and even 14 megapixel cameras. Since the issue of
pixels is often misleading and confusing, here is a short primer on pixels:
It helps to remember that pixel count doesn't determine how good the
image will be on the monitor. It only applies to: 1) How far you can zoom in on
the image without a loss of resolution, and 2) how large a good print you can
make. Image quality is determined more by lens quality, the imaging chip and
its control circuitry, etc., not to mention the ability of the photographer to
control those factors. To put the "how big" issue in some kind of
perspective, the rule of thumb I use is that (with a continuous-tone print
device such as a dye-sub or good quality ink-jet printer) you need to provide
300 pixels per inch in the print to provide "high quality"
photographic results -- ones that will stand up to close scrutiny and still
look photographic. If you can settle for "snapshot" photo quality ie
images that will be examined casually at normal reading distance or better,
then you can get by with 200 pixels per inch in the print, and for
"display" quality, meaning prints that will be viewed from several
feet away, you're OK with 100 pixels per inch or even less. (Keep in mind that
these quality levels are strictly my own personal preferences... some people
might be perfectly happy with 50-pixels-per-inch images!)
Anyway, if you've got a 2-megapixel camera (typically about 1200 x 1600
pixels in the image) the biggest print you can make and retain what I think
of as "high quality" is 4 x 6 inches. A 3-megapixel camera (let's
assume it'll be 1500 x 2000 image pixels) will let you make a print of 5 x
7 inches at the same "high quality" level. That's a difference of
about
an inch each way. If your usual need is for "snapshot" quality, you
can bump up these figures by 50%... but either way, I think it makes it pretty
clear that the 5 and 6-megapixel cameras won't make a BIG difference, unless
you plan to print 8 X 10 photos; the image on the computer monitor screen will
look the same whether you are using a 2, 3, or 6-megapixel camera. Or to put it
another way, if you have a choice of a 5-megapixel camera that's perfect for your
needs and preferences, or a 8-megapixel camera that would force you to compromise
on the features and controls you want, don’t buy the 8-megapixel model just
because it has more pixels! Even in those situations where you are zooming in
on a tooth on the monitor screen, I’ve found that a 5 megapixel camera will
allow you to blow that image up to a size where it fills the entire screen
without any loss of resolution or image quality.
When you are evaluating digital camera systems, I would recommend that you work
with a company that specializes in systems designed for the dentist. Two well-known
companies are Photomed and Norman Camera. Both produce systems that include all
the hardware and software that a dentist would need to get started in digital
photography, although they take different approaches and have subsequently
different costs of their systems. The Photomed systems are typically 5+
megapixel cameras with all components included, such as macro lens, flash
diffuser or ring flashes, memory cards, and battery charger. These systems
normally start around $1200 and can go as high as $3000 depending on the camera
type and attachments that you purchase.
From Analog to Digital
For many dentists, the transition to digital photography is exciting and opens
up many new possibilities for them. The difficulty for most, however, is trying
to figure out how to digitize their current photos and slides. There are a
number of methods of getting your prints and slides onto a computer, where they
can then be manipulated and output to different sources:
1. Photo or Picture CD. For film that hasn’t been developed or with negatives,
you can ask the photo developer to put your images on a Photo or Picture CD.
These CDs can be read by all but the most ancient CD-ROM players, and can then
be downloaded onto your computer’s hard drive.
2. Scanner. This is currently the only method for getting existing photos or
slides into a digital format. I would recommend that when you search for a
scanner; find one that has both a backlight and a transparency adapter. Models
that I have found to be particularly good are the Microtek 9800XL and the Epson
Expression 1680 Professional Series. You should look for a scanner that has the
highest dpi (dots per inch) resolution that you can afford. Better models have
at least a 1200 X 2400 dpi; the Epson, for example, has a 1600 X 3200 dpi
resolution.
3. Online. There are numerous online companies that offer online storage and
scanning of existing photos. Companies such as Ofoto and Shutterfly are is an
excellent way to store digital images, although they don’t offer scanning of
existing photos. While these online services are an option, they are hardly the
cheapest! Expect to pay from $1-10 per scan, which can get very expensive if
you have hundreds of photos and slides to be scanned.
Once you find a method of getting your analog or digital photos and slides on
to a computer, you need to have some method of storing, cataloging, and
manipulating these images.
Digital imaging is an exciting area for the new dentist and
anyone who takes the time to research their purchases will be happy with the
final result.
