Digital Radiographs: Should We Use Sensors or PSPs?

You're listening to The Dr. Phil Klein Dental Podcast from Viva Learning.com. Welcome to the show. I'm Dr. Phil Klein. Today we'll be discussing a sensible and proven strategy to implement digital radiology in the practice of pediatric dentistry. We'll talk about the advantages and disadvantages of available technologies. Our guest is Dr. Juan Yepes, a full professor in the Department of Pediatric Dentistry at Indiana University. and an attending at Riley Children Hospital in Indianapolis, Indiana. Dr. Yepes, it's a pleasure to have you on Dental Talk. Phil, it's a pleasure to talk to you again. Thank you. Thank you for inviting me, and I'm very happy always. You are an excellent, I can talk with you for hours. I don't know if our audience wants to listen to us for hours, but we can certainly talk for hours. And I'm talking to the audience now. If you missed the last podcast, we did a great one on nitrous oxide, correct use and indications in pediatric dentistry. And he covers quite a lot there, Dr. Yepes does, and it's very interesting. And I suggest if you are looking for a nitrous system, please tap into that podcast. I think you'll enjoy it. So to begin, when it comes to digital radiology systems, what's currently available for dental practitioners? Well, Phil, thank you. I'm going to enjoy this podcast a lot. You are hitting my heart. So it's like you are exactly... asking the bottom of my heart so i love it so you know in a very simple way we have two different system fields we have what we call direct digital radiology and indirect digital radiology the difference is quite simple direct digital radiology is what we call sensors that means that the device is inside the mouth of the patient the device slash sensor and as soon as the device is exposed to radiation to x-rays the image will be generated immediately, and then you will see the image over the screen. That's the direct digital radiology. The other system is indirect digital radiology, which basically, once they, we don't call that sensor, we call that phosphor plates, or well known as PSP. Once the PSP is exposed to radiation, x-rays, then you need to take this phosphor plates, or PSP, to a scanner. who is going to transform that energy who is inside the phosphor plates into an image and into an image i'm sorry and then you will see that on the screen of the computer so in some way direct immediately indirect you need to wait until you process the psp or the phosphor plate right but in both technologies the actual film it's not it's the digital film is reusable right so the sensor obviously is reusable many many times and then the same thing with the phosphor plate right that gets erased once it's processed and digitized after it's scanned and then you can go use it again correct yeah that's correct phil yeah both systems are digital you can reuse the phosphor plates because once you i will say quote quote develop the image who is the storage inside the phosphor plates you can erase that information and then the phosphor plate will be ready to get exposed again to x-rays but there is a limit You know, depending on what system you are using, what phosphor plate systems you are using in your app, sometimes they will let you use that 400 times, 350 times, 500 times. But eventually, after you use and delete, use and delete, use and delete, then you will start to see the consequences on the quality of the image. So at some point, you need to replace it. But keep in mind that the cost, you know, how much you pay for each phosphor plate is... $10, $15, $20. So it is very affordable. It doesn't mean that, oh my God, now after 400 times, I need to buy $5 ,000 for each phosphor plate. It's not like that. The sensors are more expensive. I'm sure we are going to touch base in a few minutes because there are also differences in terms of the physical characteristics of the sensor and the physical characteristics of the phosphor plates in terms of how thick they are, how easy they are, flexible they are. easy to place in different places of the mouth. So they are big difference between the two systems. Yeah, and we're going to get into all that. So briefly, tell us about phosphor plates. What are the advantages and disadvantages of phosphor plates? Yeah, just maybe we can refer as PSP. Right. And that will kind of make easier our conversation. Well, Bill, there are many, many advantages of the phosphor plates or PSP. Number one, the thickness is almost the same and i can almost delete almost because i can say the same thickness of the regular conventional films so that means that and you probably remember the conventional films because that's what we learn in dental school the ones that we will expose to the x-rays and then we are going to put it in three different tanks the developer the water and the fixer so the phosphor plates are the same thickness that equals flexibility that equals patient comfort The same. So easy to place in the mouth, easy to bend, easy to place in the floor of the mouth. Did you remember how a challenge is to take a radiograph for the floor of the mouth using sensors, which we are going to talk in a few minutes. So number one, PSP, flexibles, thin. Also, this is a big advantage. They come pretty much in the same sizes than traditional films. zero, double zero, one, two, three, and four, and even occlusal. Remember the occlusal film? For sure. To be a size four that we used to have a maxillary occlusal and mandibular occlusal, which I will tell you, Phil, I was the director of radiology at the University of Kentucky for a long time, almost 10 years. I miss a lot the occlusal projections that for some reason we don't see a lot of occlusal projections in these days. But the occlusal projection used to be a perfect projection to have an evaluation of the anterior maxilla as well as the anterior mandible. So with PSP, because they come in different sizes, you can find a size 4 PSP. You can find a size 3, a size 2, a size 0, and double 0. Also, PSP, and there is a big debate about that, so I need to be so careful with the audience because I really don't want to say something that... It may well create some controversies or confusion. But generally speaking, with phosphoroplates, you may have a little bit better resolution. And I need to be very careful here. But, you know, sometimes as a pediatric dentist, we are looking for, you know, the interproximal area between K and L. And we take a bite wing. We really need as better resolution as we can because we need to see that tiny... occlusal distal lesion into number L. So with the PSP, you may get a little bit better resolution, spatial resolution, comparing with the sensors. Now, obviously, in my opinion, this is not a disadvantage, but it's a difference with the sensors. You need to take the PSP out of the mouth, and then you need to move into the scanner, and then you need to place that into the scanner, and then you need to wait less than a minute until you see the image. Finally. I will tell you one more advantage that you are going to be shocked. That, in my opinion, is a huge advantage of PSP. Because it takes a little bit longer to see the image. We pay more attention in the way that we take the radiograph. Psychologically, for sure. We don't want to go to that minute again. On the other side, sensors, because basically you... the bottom and then you see the image immediately you can pretty much in less than a second take one more and then take one more until you get the image that you are looking for but yes you expose the patient three times to get one with the phosphor plates PSP because we know we need to take the PSP into the scanner and then wait until we see the image over the screen That time, psychologically, will make you to take the image, to take the radiograph, paying more attention using the XCP or the X-ray positional device to make sure that you don't have con cuts, make sure that you have the proper angulation. With the sensors, retakes are always a problem. So you have a tremendous amount of experience in radiology being the previous department chairman at Kentucky. I realized that the... incidence of retakes using sensors is probably higher because of the fact that it's so easy to take another one. What about the difference between traditional film and PSPs? Are the number of retakes pretty much the same between those two formats? In the perfect world, perfect world, and I know that in pediatric dentistry is different from adult dentistry. In adult dentistry, you have a patient that you ask, open the mouth, and they open, don't move, they don't move. From the front, you have different patients, different levels of cooperation that they may well impact the quality of the radiographs. But generally speaking, the amount of retakes is supposed to be around 10%. That means that for every 10 films that you're taking in an office, about one you need to retake. I always, when I lecture about these issues, I always suggest to the dentist and to everybody listening to this podcast that just pick up a week, don't tell your employees, During one week, track the number of retakes because that is an amazing educational tool. You can provide feedback to your staff members if you noted that Susie or Erica, who are taking the radiographs, the retakes is way above 10%, 20%, 30%, 40%. I studied many times the amount of retakes using sensors and the amount of retakes using PSP. In fact, I run a couple of studies when I was in Kentucky because this is a... measure that we want to keep it. And we want to show that when they ask for quality improvement projects in radiology. So with the sensors, the amount of retakes without any question is higher than the amount of retakes with PSP and conventional films. Conventional films and phosphor plates are almost at the same level of retakes, around 10 to 15%. Unfortunately, Phil, with the sensors, sometimes we see retakes close to 40, 50%. That means that to get one film, you need to take two. Yeah, and that's really, that's not a good thing for radiation, especially in a pediatric practice. And that's something that every dentist and every staff member should be very concerned about is how much radiation you give a patient. And if you can minimize that with reducing retakes, that's an important thing. What is the importance of, and we touched on this right now, what is the importance of digital radiology in the context of radiation safety? It's a huge, huge importance. The sensors and the PSP, they need less radiation to create an image. They need less radiation. It is calculated that both systems, they require between 30 to 50 percent. 30 to 50 percent, sometimes my Kentucky accent make these conversations more challenged, as you know, but between 30 to 50 percent less radiation to create an image. So no matter what digital radiology system you are using, you are in the correct pathway if you want to create an office who is safe in the use of radiation. In the same way that you want to recycle paper, that you want to recycle and you separate and you want to be nice with the planet. and you separate your garbage or your trash in different containers, well, you also need to be also friendly with the thyroid gland, with the salivary glands, and the way to be in an office that is really conscious about radiation is using digital radiology. Now, we also need to be careful because, as I mentioned before, you may actually end up providing more radiation if you don't control the number of retakes. Finally, If you don't adjust the settings of the x-ray machine according to the system that you are using, without you knowing, you may are actually using more radiation than the really radiation that you needed. Remember, Phil, with digital radiology, you can manipulate the image over the screen. In the old days when you were in the dental school and I was in the dental school, if the film was dark, we didn't have any options. You will need to take it again. If the film was too light and you are an endodontist, imagine. too light you barely see the file inside the tooth you don't know if it's outside or inside you will need to retake it yes but in these days if the film is too bright or if the film is too dark you can still just move into your mouse and you can adjust a little bit the the um the bright and and the density the contrast of the image and you can make that image okay for you but you may pay a price of that because you use an amount of radiation too high and you didn't know that because you just can't adjust the radiograph using the mouse. So digital radiology is a wonderful tool to save radiation, but need to be careful. The dentists need to be very, very conscious about the retakes and conscious about the using the proper settings for the system that you have in the office. Something that we need to talk in this podcast, and you may are going to ask me, but I need to say it so we don't miss this, is what is the best system? What is my recommendation? Either sensors or PSP? Because I have a nice answer to that, and I have a strong opinion about that. So I don't know if you want to know. No, I'm going to ask you. Before I ask you that, though, tell me why children are more sensitive to radiation than adults. Yes, we know that for a long time. We know that since 19... 2008, I believe. Thank you to two very famous radiation physicists, researchers. We know we call, I will tell you the name, is the Bergen and Tribundo law. Basically, thank you to these two researchers. We know that some cells in the body, some tissues are more sensitive to radiation. Some of these tissues are the tissues who are active replicating. As young as you are, more active replicating tissues you have. More cells are active in dividing. So children, generally speaking, are probably 30 to 40% more sensitive to radiation than adults. The thyroid gland is more sensitive to radiation. The salivary glands are more active replicating, and that make kids... a lot more sensitive than you or me when we are exposed to radiation. So that's why it's so important to adjust that radiation on those machines, like you said, creating x-rays that are diagnostic, but you're minimizing, you're doing it with the minimal amount of radiation to the patient. Yeah, so, okay, so here's the big question that you are dying to answer. We've got PSPs, we've got sensors. You want to tell us why you like one better, and nobody else could tell us this better than you. You've been through... years and years of teaching radiology you're in it all the time as a clinical dentist and you have a tremendous passion for radiology in fact you told me in the past that you switched to rectangular collimation which was a tough learning curve for you and that also is a tremendous way to get higher resolution and reduce radiation. That may be another podcast in itself. Maybe you can touch on that before we end. But PSP Sensor, tell us why you like one over the other. You know, I am a, and thank you. I, you know, after all these years, you know, 10 years working as a director of radiology at the University of Kentucky, I was responsible to move the entire dental school from conventional radiology to digital radiology. And we did that in a summer break. So I went through the whole process of moving from conventional to digital. And then later on, I accepted a position as a dental pediatric dentistry resident. So I, you know, really, radiation safety is really very, as I mentioned to you at the beginning of this podcast, is very close to my heart. Phil, no question, the best system is both systems. No question about that. I recommend in every single lecture that I give, in every single podcast, in every informal conversation with friends in the hallway, the best system is to have both systems. I think so both systems will give you the whole spectrum of the advantage and the disadvantage. What I'm telling you is in these days in contemporary dentistry, dentistry of the 21th century, we need to be able to have both systems because the... The sensors are wonderful. If you have a big mouth, if you have a patient who is cooperative, if you have a patient who understands the commands, remember biting over the cable can ruin the sensor. And that is 6K, 7K. And then also at the same time, having in the office phosphor plates or PSP will work perfect with young kids. And that is usually my battle with... with with the companies when they tell me oh no you can run exclusively sensors in a pediatric dental practice you know one thing is to say that during a conversation and i want to invite you to be in a pedo practice trying to place a sensor number one in the mouth of a three-year-old or in the mouth of a four-year-old it's challenge it's very challenge so a hybrid system is the ideal system in digital radiology you can And general dentists or pediatric dentists, it doesn't matter if you are working exclusively with kids. I work with kids, but some of my patients are 18-year-old, bigger than you and bigger than me. And in my office, I have both systems. And my assistants, they know that sometimes when we have a patient who is cooperative, big mouth, we use sensors. And when we have patients with a small mouth and maybe more challenge, we use phosphor plates. um also one of the advantages of the phosphor plates is it's a lot more portable because in these days i'm using handheld x-ray devices i have one that is wonderful and i carry that in the entire office which one which one is that just so our audience knows what you're using on the handheld x-ray to go um that's right to go yeah that's the name is very x-ray to go it really means that it's from a company digi dogs and then i go around with that it looks like a camera And so I go around with that, and sensors will need to have a computer next to you, will need the sensor to be plugged with the computer. But in these days, with the dental office very active and kids moving, so one of the advantages of the sensors, I'm sorry, one of the advantages of the PSP is that you can take a radiograph anywhere, really anywhere. You can go in operative one, operative room number two, open bay, whatever you need it, you can take it. Obviously, you need to keep six feet away, of course, but phosphoplase will give you that flexibility. But in some patients, sensors will work better. Why would a sensor work better in another patient? You know, patients who are adults, adolescents, who they have more understanding and they are more cooperative. They know to be careful not biting the cable. Yeah, I have sensors in my office and you just... expose the sensor, and you can see the image immediately. But I don't have any problem whatsoever to wait one more minute when I use PSP. So it really, and I love this podcast, and you know, for the listeners, for having a hybrid system will bring to your world the benefits of the both systems that you can make your judgment when you will use direct, when you are going to use indirect. As a pediatric dentist, though, do you find yourself using PSPs most of the time, even though you have a hybrid system? I love the question. I love it. The other day I look at that, it's almost 50-50. We pediatric dentists, we see little ones, and I use PSP. And remember, PSP, less retakes. And I am very passionate about the retakes. You know, sometimes, you know, I tell my assistant, you try one or maybe twice, but you are not going to try 10 times to get one film. With the sensors, it's a lot more easier to retake the film. So the temptation, I don't know if I pronounced correctly, the temptation to retake with the sensors is twice. You just put back and then you see the image. So you're using 50-50 in your practice, in your pediatric dentist. Is it that you're using the sensor half the time? because those patients can tolerate it and the benefit is you get the film the results of the film immediately yes is that the main impetus to using the sensor is boom i've got it you click the switch it's on the screen yes if i'm looking at how a crown is seated and i and i have the patient in the chair and i want to know immediately because if i don't if the crown is not fully seated i may need to take it out and put it back then I will use the benefits of the sensors, of course. Right. So for the immediate image, that's an advantage. But if you're taking a full mouth series, you're doing that every, I don't know how many years, what the interval is, or take a full mouth series, and especially on a new patient, you're not going to look at that full mouth series right there. You'll look at that maybe when the next time the patient comes back, you'll have a treatment plan set up or whatever. Then PSPs work fine, right? Because there's no time constraint on the workflow. Does that make sense? Absolutely. Absolutely. Plus, I use, and I will mention, I use the scanner from Air Techniques, which, believe it or not, is also Wi-Fi. So I can put the scanner in any place in my office, and I can put the PSP inside the scanner, and then I can capture the image in any of the computers that we have in the office. Now, as an endodontist, which I am, retired. You are retired. You're still an endodontist. Yeah, that's right. I'm an endodontist retired. You can see by my questions how long it's been since I've been behind the chair. But basically, for an endodontist, if I'm doing a length film, I want an immediate response on that film. Are most endodontists using sensors? Yes, I would say that in that particular situation. Remember, the waiting time with the PSP is now the 20 minutes in our days in dental school that we used to go to that dark room and everybody gossiped during that time. You didn't see the face of anybody. Right. Yeah. I mean, to me, you know, I never had, when I retired, I didn't have any of this stuff. My staff went into the dark room and dipped developer, water, and fixer. And if the film wasn't, you know, translucent enough, that means they didn't put it in the developer long enough, if I remember correctly. And if the image didn't stay where it was, that means they didn't fix it long enough, whatever. But these are days of the past. I mean, I was just curious to know whether or not I would assume sensors was more. applicable to endodontists, just asking for my own curiosity as being one. So I'm surprised to hear it's 50-50, though, from someone that's in the pediatric business. I would have thought 90 -10. And I'm very close. I monitor my retakes, so I know. when the film is a PSP or when the radiograph came from a sensor. It's almost 50-50. That's right. And the sensor costs today around $7,000? Probably go from 5K all the way to 8K to 9K. Okay. Remember, with the sensors, you don't have a size 4. So you don't have the ability to take occlusal in adult patients. Like we have the ability to do that with PSP because we have the size 4. But it's a lot more... options in terms of the sizes when you use PSP compared with sensors. Yeah, I'm wondering what the proportion of usage is for GPs. Yours is 50-50. Do you think GPs is 70-30 sensor to PSP? Some GPs, they are hybrid, but I am inclined to think that the majority of GPs are either PSP or sensors, and maybe the majority sensors. That would be my guess. Yeah, very interesting. So the system that you use right now on the PSP side, you mentioned is by Air Techniques. Is there anything in particular about that system that you like that you'd like to share with us? Too many particular things, Phil. I am in love, if I can use that term, with the PSP system of Air Techniques. The scanners, the fission of the scanners, the reliability of the scanners are just... amazing good the phosphor plate the psp from air techniques are perfect the scanners are perfect easy compatibility with mac or if you don't you use a pc the communication is very smooth they also communicate very well with electronic health records because remember phil in our days we have paper charts so we used to have the radiographs inside a little envelope attach it to to the paper chart but in these days We use different electronic health record systems. So you need to make sure that the digital system that you are using is compatible with the electronic health record that you have. I use Dentrix Ascend. Dentrix Ascend is a cloud-based. The cloud-based Dentrix, yes. I use that. Henry Schein 1, I think. Henry Schein 1 runs that. Yeah, I have three offices. I didn't mention that to you, but I opened one office, two offices. Now I have three pediatric dental offices. So it's wonderful to have everything in the cloud. The PSP systems, the interface with the cloud system is very smooth, and I'm not an IT guy. I have somebody who deals with that, but we never have an issue. So I definitely, that's what I use in my office. That's what I start to use in the first office, in the second office, and that's what we are going to place in the third office that I'm opening by the end of this month. Yeah, and also some of the things that dentists should consider when purchasing equipment like this is the support. available by the manufacturer that's really important when it comes to technology uh digital devices like this if there's an issue with any of the equipment it's comforting to know that the clinician could call or the staff can call and get some answers like why something might not be functioning because we're running a practice and if something goes down obviously the production is going to drop dramatically. And Phil, when that happens, we always, always contact the company and there is always somebody who can talk with our IT expert. There is nothing more frustrating, believe me, and you know this, that having a patient in the chair ready to take a couple of radiographs to take decisions because we need the radiographs to take a decision, to pull a tooth or to do a root canal or whatever and having an issue with the system. Honestly, with Air Techniques, not just only I have phosphoroplate, but also my panoramic machine is Air Techniques, which is a wonderful, is the ProVecta, which is the most crispy, clean panoramic images that I've ever seen in my life. And I have been working in radiology for a long, long time. And interesting enough, Air Techniques, I know they didn't do this because I said this, but now they are also hybrid. Now Air Techniques is offering sensors. And the other day, I was looking at the website of Earth Techniques, and it's a wonderful video about why an office is important to be hybrid. So I was thinking, oh, my God, somebody listening to me. Yeah, don't be so modest, Dr. Yepes. I think that your input into this whole concept of hybrid offices certainly... made an impression on air techniques. I know the company myself, some of the people there, and they're just incredibly open to getting feedback from clinicians and researchers to improve their products and so forth. Any last words before we wrap it up? Yeah, that's interesting that a company that for many, many years was into the PSP business now is also in the sensor business because realize that, you know, that it's a market for the sensors. I just want to thank you, Phil, and I want to thank you, the audience. This is, as I, my first. when I started this podcast is, these issues of radiation safety are inside my aorta. So, you know, the other issue is just to remind everybody listening to this podcast to think seriously, to move into rectangular collimation. Rectangular collimation is the single most effective way to decrease the amount of radiation in a dental office. I know it's a challenge because if you do that abruptly, then you are starting to, you probably will start to see a lot of concats and a lot of... you know, kind of a stress. So you need to train your staff to take the films correctly. But rectangular collimation is also an absolutely, absolutely mandatory step that dentists need to do these days in the office. Phil, thank you so much. Very good, Dr. Yepes. Thank you so much. And we'll see you on the next podcast. We really appreciate your input. Thank you. Thank you.