Convex triangular vs. cylindrical field of view: how does the shape of the FOV affect radiation dose?

OBJECTIVE: To compare the dosimetry between convex triangular fields of view (FOV) and similar dimension cylindrical FOVs of two cone-beam computed tomography (CBCT) models. METHODS: Optically stimulated luminescence dosimeters (OSLDs) were placed in fiducial anatomical locations in an anthropomorphic phantom representing an adult head male for dosimetry scans. Convex triangular FOVs (100 × 80 mm/maxilla-mandible; 100 × 50 mm mandible; 100 × 50 mm/maxilla) from Veraviewepocs 3D R100 (J. Morita, Kyoto, Japan) (R100) and Veraview® X800 (J. Morita, Kyoto, Japan) (X800) and cylindrical FOVs from R100 and X800 (80 × 80 mm/maxilla-mandible; 80 × 50 mm/mandible; 80 × 50 mm/maxilla) were obtained, resulting in 12 different scan protocols. Equivalent doses for each relevant organ/tissue and the effective dose for each protocol were calculated. Mean effective doses were compared by the two-way analysis of variance (ANOVA) with Tukey's post hoc test to evaluate the effect of the FOV and device (α = 0.05). RESULTS: The effective doses ranged between 69 and 324 µSv for the convex triangular FOVs and 76 and 332 µSv for the cylindrical FOVs. Convex triangular FOVs from the R100 device had effective doses 2.3 to 15.3% lower than their corresponding cylindrical FOVs with similar height (p < 0.05), and that difference ranged between 8.8 and 11.8% for the X800 device (p < 0.05). CONCLUSION: Convex triangular fields of view delivered slightly lower effective doses than the cylindrical fields of view of similar dimensions in the R100 and X800 CBCT devices. CLINICAL RELEVANCE: Understanding the influence of the image geometry formation in effective dose allows optimization to reduce patient dose.

Image retake rates of cone beam computed tomography in a dental institution.

OBJECTIVES: To investigate the frequency and reasons for retaking cone beam computed tomography (CBCT) scans in an oral and maxillofacial radiology imaging clinic in a dental institution. MATERIALS AND METHODS: A retrospective cohort chart audit of the patient image database was performed for 1737 patients attending the Diagnostic Imaging clinic at the Prince Philip Dental Hospital from February 2016 to May 2019, and the rate of, and reasons for, CBCT image re-exposure was tallied. Patient demographics (age and gender) and CBCT acquisition parameters (CBCT unit, field-of-view (FOV), scanned region of interest, and exposure time) were recorded and correlated to retake analysis. RESULTS: The retake rate was 4.6% (80/1737). The most common reasons for re-exposure were incomplete FOV coverage (57.5%) and motion artifacts (27.5%). Patients under 12 years of age had a significantly higher risk for motion artifacts. CBCT for the temporomandibular joint (TMJ) had a significantly higher risk for incomplete FOV coverage. CONCLUSIONS: Children (less than 12 years of age) demonstrate a higher frequency of retakes, principally due to motion artifacts. TMJ CBCT examinations have a higher frequency of retakes due to an incomplete FOV coverage. CLINICAL RELEVANCE: Information regarding the frequency and reasons for CBCT retakes is beneficial to identify procedures, practices, or patients susceptible to additional radiation exposure and implement appropriate and specific quality control protocols.

In-House Digital Workflow for the Management of Acute Mandible Fractures.

Computer-aided design and additive manufacturing are revolutionizing oral and maxillofacial surgery. Current methods use virtual surgical planning sessions and custom plate milling via third-party vendors, which is costly and time-consuming, negating the effectiveness in acute facial trauma. This technical note describes a state-of-the-art in-house expedited digital workflow for computer-aided virtual fracture reduction, 3-dimensional printing, and preoperative reconstruction plate adaptation for the management of an acute mandible fracture. This process uses the computed tomographic scan a patient receives in the emergency department or clinic. The DICOM (Digital Imaging and Communications in Medicine) data are transferred into US Food and Drug Administration-approved software, in which the fracture is segmented and virtually reduced based on condylar position, midline symmetries, and occlusion if present. The reduced mandible is then printed, which serves as a template for preoperative reconstruction plate adaptation. This method facilitates a virtually reduced fractured mandible, 3-dimensionally printed model, and ideally adapted plates ready for sterilization before surgery within 2 hours after DICOM upload.

Accuracy of linear measurements on CBCT images related to presurgical implant treatment planning: A systematic review.

OBJECTIVE: The aim of this systematic review was to identify, review, analyze, and summarize available evidence on the accuracy of linear measurements when using maxillofacial cone beam computed tomography (CBCT) specifically in the field of implant dentistry. MATERIAL AND METHODS: The search was undertaken in April 2017 in the National Library of Medicine database (Medline) through its online site (PubMed), followed by searches in the Cochrane, EMBASE, ScienceDirect, and ProQuest Dissertation and Thesis databases. The main inclusion criterion for studies was that linear CBCT measurements were performed for quantitative assessment (e.g., height, width) of the alveolar bone at edentulous sites or measuring distances from anatomical structures related to implant dentistry. The studies should compare these values to clinical data (humans) or ex vivo and/or experimental (animal) findings from a "gold standard." RESULTS: The initial search yielded 2,516 titles. In total, 22 studies were included in the final analysis. Of those, two were clinical and 20 ex vivo investigations. The major findings of the review indicate that CBCT provides cross-sectional images that demonstrate high accuracy and reliability for bony linear measurements on cross-sectional images related to implant treatment. A wide range of error has been reported when performing linear measurements on CBCT images, with both over- and underestimation of dimensions in comparison with a gold standard. A voxel size of 0.3 to 0.4 mm is adequate to provide CBCT images of acceptable diagnostic quality for implant treatment planning. CONCLUSIONS: CBCT can be considered as an appropriate diagnostic tool for 3D preoperative planning. Nevertheless, a 2 mm safety margin to adjacent anatomic structures should be considered when using CBCT. In clinical practice, the measurement accuracy and reliability of linear measurements on CBCT images are most likely reduced through factors such as patient motion, metallic artefacts, device-specific exposure parameters, the software used, and manual vs. automated procedures.

Group 5 ITI Consensus Report: Digital technologies.

OBJECTIVES: Working Group 5 was assigned the task to review the current knowledge in the area of digital technologies. Focused questions on accuracy of linear measurements when using CBCT, digital vs. conventional implant planning, using digital vs. conventional impressions and assessing the accuracy of static computer-aided implant surgery (s-CAIS) and patient-related outcome measurements when using s-CAIS were addressed. MATERIALS AND METHODS: The literature was systematically searched, and in total, 232 articles were selected and critically reviewed following PRISMA guidelines. Four systematic reviews were produced in the four subject areas and amply discussed in the group. After emendation, they were presented to the plenary where after further modification, they were accepted. RESULTS: Static computer-aided surgery (s-CAIS), in terms of pain & discomfort, economics and intraoperative complications, is beneficial compared with conventional implant surgery. When using s-CAIS in partially edentulous cases, a higher level of accuracy can be achieved when compared to fully edentulous cases. When using an intraoral scanner in edentulous cases, the results are dependent on the protocol that has been followed. The accuracy of measurements on CBCT scans is software dependent. CONCLUSIONS: Because the precision intraoral scans and of measurements on CBCT scans and is not high enough to allow for the required accuracy, s-CAIS should be considered as an additional tool for comprehensive diagnosis, treatment planning, and surgical procedures. Flapless s-CAIS can lead to implant placement outside of the zone of keratinized mucosa and thus must be executed with utmost care.

Pediatric cleft palate patients show a 3- to 5-fold increase in cumulative radiation exposure from dental radiology compared with an age- and gender-matched population: a retrospective cohort study.

OBJECTIVE: The objective of the study was to compare estimates of pediatric cumulative exposure and lifetime attributable risk (LAR) of radiation-induced cancer from dental radiology between cleft palate (CP) subjects and age- and gender-matched controls (non-CP), with and without orthodontic treatment. MATERIALS AND METHODS: The radiation exposure frequency of CP subjects and non-CP controls with and without orthodontic treatment was compared for two-dimensional radiography (intra-oral, panoramic and cephalometric radiography), computed tomography (CT), and cone-beam CT (CBCT) using cumulative radiation dose as an estimate. From this dose estimate, the age- and gender-dependent risk for radiation-induced stochastic effects was calculated for each patient group. RESULTS: CP patients received more radiographic examinations than non-CP controls, with the exception of intra-oral radiographs. The cumulative dose to CP patients was considerably higher (1963 µSv at the age of 20 years) than non-CP patients with (597 µSv) and without (383 µSv) orthodontic treatment, primarily due to the higher frequency of CT scanning. Accordingly, CP patients had a three to five times higher LAR than non-CP patients. CONCLUSIONS: This study suggests a significantly higher lifetime radiation exposure to CP patients than non-CP controls from dental radiographic procedures. Diagnostic benefits from the use of CT and CBCT in children must be justified and appropriate dose optimization strategies implemented. CLINICAL RELEVANCE: The present study indicates the need for proper justification and optimization of pediatric exposures in dentistry, with a special focus on high-risk groups.

Apical root resorption during orthodontic treatment with clear aligners: A retrospective study using cone-beam computed tomography.

INTRODUCTION: We aimed to investigate the incidence and severity of orthodontically induced inflammatory root resorption (OIIRR) on maxillary incisors with clear aligner therapy using cone-beam computed tomography and to identify possible risk factors. METHODS: The root lengths of maxillary incisors were measured on orthogonal images from pretreatment and posttreatment cone-beam computed tomography examinations of 160 patients who received comprehensive orthodontic treatment with clear aligners. RESULTS: Mean absolute reductions in root length varied between 0.47 ± 0.61 mm and 0.55 ± 0.70 mm and were not significantly different between maxillary central and lateral incisors. The prevalence of severe OIIRR, defined as both maxillary central incisors experiencing greater than a 25% reduction in root length, was found to be 1.25%. Potential risk factors included sex, malocclusion, crowding, and posttreatment approximation of apices to the cortical plates. Race, interproximal reduction, previous trauma to the teeth, elastics, age, treatment duration, and pretreatment approximation of apices to the cortical plates did not significantly affect the amount of OIIRR. CONCLUSIONS: Comprehensive treatment with clear aligners resulted in minimal root resorption. Sex, malocclusion, crowding, and posttreatment approximation to the cortical plates significantly affected the percentage of change in root length. Posttreatment approximation of root apices to the palatal cortical plate showed the strongest association for increased OIIRR.

The emerging role of maxillofacial radiology in the diagnosis and management of patients with complex periodontitis.

Contemporary periodontal therapy has evolved to become more interdisciplinary and increasingly involves more complex treatments, including bone and soft-tissue regenerative procedures. Therapeutic options require an imaging modality or combination of techniques that are capable of providing a diagnostic osseous baseline and facilitating quantification of smaller increments of bony change, both loss and additive, which are comparable over time. Intra-oral and panoramic radiography are the modalities most commonly used to identify the location, quantify the amount and the pattern of alveolar bone loss and determine response to therapy. Cone-beam computed tomography imaging offers specific advantages for periodontal diagnosis in that three-dimensional images of dental and alveolar bone structures can be rendered with accuracy. Cone-beam computed tomography has been shown to be clinically efficacious in demonstrating localized defects, such as furcation involvement and intrabony vertical and buccal/lingual defects, and in assessing the effects of regenerative therapy. In these situations, limited-field-of-view, high-resolution protocols are indicated.

Filtered back projection vs. iterative reconstruction for CBCT: effects on image noise and processing time.

OBJECTIVES: To assess the effect of standard filtered back projection (FBP) and iterative reconstruction (IR) methods on CBCT image noise and processing time (PT), acquired with various acquisition parameters with and without metal artefact reduction (MAR). METHODS: CBCT scans using the Midmark EIOS unit of a human mandible embedded in soft tissue equivalent material with and without the presence of an implant at mandibular first molar region were acquired at various acquisition settings (milliamperages [4mA-14mA], FOV [5 × 5, 6 × 8, 9 × 10 cm], and resolutions [low, standard, high] and reconstructed using standard FBP and IR, and with and without MAR. The processing time was recorded for each reconstruction. ImageJ was used to analyze specific axial images. Radial transaxial fiducial lines were created relative to the implant site. Standard deviations of the gray density values (image noise) were calculated at fixed distances on the fiducial lines on the buccal and lingual aspects at specific axial levels, and mean values for FBP and IR were compared using paired t-tests. Significance was defined as p < 0.05. RESULTS: The overall mean for image noise (± SD) for FBP was 198.65 ± 55.58 and 99.84 ± 16.28 for IR. IR significantly decreased image noise compared to FBP at all acquisition parameters (p < 0.05). Noise reduction among different scanning protocols ranged between 29.7% (5 × 5 cm FOV) and 58.1% (5mA). IR increased processing time by an average of 35.1 s. CONCLUSIONS: IR significantly reduces CBCT image noise compared to standard FBP without substantially increasing processing time.

Comparison of technical errors in pediatric bitewing radiographs acquired with round vs rectangular collimation.

OBJECTIVE: To compare technical errors in bitewing radiographs acquired with round vs rectangular collimation in a hospital-based pediatric dentistry training program. STUDY DESIGN: A retrospective chart review was conducted of 176 digital bitewing radiographs exposed with round collimation and 106 exposed with rectangular collimation. The number of re-exposures was calculated, and errors in central ray entry (CRE; "cone cuts"), horizontal and vertical positioning, and angulation were measured. RESULTS: There were no greater re-exposures but significantly more CRE errors with rectangular collimation (21.7%; n = 23; 95% confidence interval [CI], 13.9%-30.0%) than with round collimation (3.4%; n = 6; 95% CI, 0.7%-6.1%). CRE error location, horizontal positioning errors, and size of horizontal overlapped contacts were statistically different but not clinically important. CONCLUSIONS: Use of rectangular collimation resulted in increased CRE errors but no other clinically significant problems. This technique should be used to reduce radiation exposure to patients.

Implant Site Development Using Titanium Mesh in the Maxilla: A Retrospective Study of 58 Mesh Procedures in 48 Patients.

This article presents a retrospective case series of implant site development using titanium mesh (Ti-mesh) in the maxilla. A total of 58 mesh procedures in combination with several different bone grafts (allograft, cellular allograft, and bovine xenograft) and biologics (including recombinant human platelet-derived growth factor, autogenous platelet-rich growth factor, and recombinant human bone morphogenetic protein-2) were performed in 48 patients. Ti-mesh guided bone regeneration procedures were performed 2 to 3 months after extraction of nonrestorable/hopeless teeth, and the implants were placed 6 to 8 months postaugmentation. The mean initial ridge width was 2.0 ± 1.0 mm, and the mean horizontal gain after Ti-mesh procedures was 4.7 ± 1.6 mm. The ridge width was first measured on the cross-sectional presurgical CBCT image and then confirmed clinically during surgical procedures. No statistical difference in the horizontal gain was found among different combinations of bone grafts and biomaterials. Ti-mesh exposure occurred 22% of the time. The middle-aged adults (odds ratio [OR] = 8.59; P = .046) and older adults (OR = 16.66; P = .02) had significantly higher chances of mesh exposure compared to young adults. While all implants were successfully placed, about 56% of the implants had < 2 mm of bone to the facial aspect of the osteotomy and received additional contour augmentation when placed in a prosthetically appropriate position for a screw-retained restoration. This study demonstrates that although Ti-mesh procedures result in significant bone regeneration in narrow alveolar ridges to predictably allow implant placement, the age-related mesh exposure rate and frequency of need for additional contour grafting should be discussed with patients.

Radiographic protrusion of dental implants in the maxillary sinus and nasal fossae: A multidisciplinary consensus utilising the modified Delphi method.

The aim of the present study was to generate an international and multidisciplinary consensus on the clinical management of implant protrusion into the maxillary sinuses and nasal fossae. A total of 31 experts participated, 23 of whom were experts in implantology (periodontologists, maxillofacial surgeons and implantologists), 6 were otolaryngologists and 2 were radiologists. All the participants were informed of the current scientific knowledge on the topic based on a systematic search of the literature. A list of statements was created and divided into three surveys: one for all participants, one for implant providers and radiologists and one for otolaryngologists and radiologists. A consensus was reached on 15 out of 17 statements. According to the participants, osseointegrated implants protruding radiographically into the maxillary sinus or nasal fossae require as much monitoring and maintenance as implants fully covered by bone. In the event of symptoms of sinusitis, collaboration between implant providers and otolaryngologists is required. Implant removal should be considered only after pharmacological and surgical management of sinusitis have failed.

Utility and effectiveness of computer-aided diagnosis of dental caries.

Digital radiography has created a growing opportunity for computer-aided diagnostic (CAD) tools. The Logicon Caries Detector (LCD), with upgraded CAD software based on user feedback, was re-evaluated for its effectiveness via a retrospective clinical study. Using the upgraded LCD software, 12 dentists (evaluators) blindly assessed 17 radiographs taken by another (attending) dentist, who restored 28 proximal surfaces. The attending dentist confirmed the presence of early dentinal caries, as well as identifying 48 surfaces as caries-free or with enamel caries only subject to noninvasive treatment. The radiographs, imported into the software using a digital imaging and communications in medicine (DICOM) reader, were visually assessed under typical operatory lighting conditions, then with the aid of the software's density analysis tool. The effectiveness of the evaluators was gauged by calculating two measures of performance, sensitivity and specificity, for the detection and classification of dentinal caries. Sensitivity among all evaluator dentists was 30% with the initial image; 34% with the brightness and contrast adjusted image; 39% when the image was sharpened; and 69% when the density analysis tool was utilized. Specificity was found to be 97% with the initial image; 95% with the brightness and contrast adjusted image; 93% with the sharpened image; and 94% when the density analysis tool was used. Compared to the unaided eye, the LCD can significantly improve dentists' ability to detect and classify caries. Dentists may be able to find twice as much early dentinal caries requiring restoration (or at least aggressive noninvasive treatment) than previously, while not unnecessarily restoring additional healthy teeth. The LCD enables dentists to obtain more information from dental digital radiography than is possible with the unaided eye, leading to improved patient care.

Early Loading of Posterior Nonsubmerged Titanium Implants with a Modified Sandblasted and Acid-Etched Surface: A Prospective Case Series with Up to 149 Months of Follow-up.

The purpose of this prospective study was to evaluate the success rates and prosthetic complications of implants with a modified sandblasted and acid-etched (SLA) surface inserted for posterior single-implant crown restorations. Final crowns were placed 3 to 4 weeks after surgery, and patient follow-up spanned 10 years in a private practice setting. A total of 22 patients (8 women, 14 men) with 25 posterior implants placed (16 mandible, 9 maxilla) were selected, including only implants for posterior single-implant crowns with insertion torque values of ≥ 35 Ncm at placement. Twenty-one implants passed the reverse torque test at 3 to 4 weeks after implant placement, and final restorations were placed. Three patients (4 implants) had "spinners," and there was one patient dropout after completion of the final restoration. All patients were recalled for clinical exams, digital periapical radiographs, and clinical photos at short-term (≤ 5 years) and long-term (> 5 years) follow-up appointments. The Community Periodontal Index of Treatment Needs was also determined at the initial and follow-up visits. Crestal bone level was measured at crown placement (T1), short-term follow-up (T2; mean: 29.4 months), and long-term follow-up appointments (T3; mean: 114.4 months). Twenty patients (23 implants) returned for examination at T2, and 15 (18 implants) were available at T3. For the 17 implants available at all evaluations, statistically significant bone loss was found from T1 to T2 (0.23 ± 0.30 mm), and the mean crestal bone level appeared stable from T2 to T3. Based on clinical and radiographic findings, the success rate for the implants and restorations at T2 and T3 was graded as 100%. Therefore, it can be stated that an early loading protocol of 3 to 4 weeks using a modified SLA surface at premolar/molar single-tooth locations can result in favorable clinical and radiographic long-term results.

Essentials of maxillofacial cone beam computed tomography.

Cone beam computed tomography (CBCT) is a diagnostic imaging modality that has shown rapid adoption in clinical dental practice over the past 10 years. CBCT images provide high quality, accurate 3-dimensional (3D) representations of the osseous elements of the maxillofacial skeleton. The purpose of this article is to provide (1) an introduction to maxillofacial CBCT technology, (2) an understanding of the relative patient radiation dose, and (3) to underline the appropriate use of CBCTas a diagnostic imaging modality with specific clinical applications.

A survey on radiation exposure reduction methods including rectangular collimation for intraoral radiography by pediatric dentists in the United States.

BACKGROUND: The authors conducted a survey of the American Academy of Pediatric Dentistry (AAPD) to determine awareness of the Image Gently Campaign in Dentistry (IGCD) and to ascertain radiologic practices, including radiation dose-reduction strategies such as rectangular collimation. METHODS: An institutional review board approved an electronic survey sent to 7,087 AAPD members covering practitioner demographic characteristics, radiographic techniques, and dose-reduction practices, including rectangular collimation. Responses were tabulated and analyzed using binomial tests, χ2 tests, and Fisher exact tests. RESULTS: A total of 1,124 pediatric dentists or residents in pediatric dentistry responded, (response rate 16%, margin of error ± 2.7%). The largest group (23.8%) graduated after 2010. More than 90% indicated that they followed American Dental Association (ADA)-AAPD radiation exposure guidelines, but only 33.5% were aware of IGCD. Almost all respondents used direct digital systems, storage phosphor plates, or both. Only 22.3% (n = 220) used rectangular collimation. Nonusers indicated that they were unfamiliar with collimation (33.3%) or concerned about potential for increased cone cuts (30.2%), 11.6% of respondents were unaware of any regulatory requirements for inspections of radiographic equipment recurring at regular intervals, and 4.1% of respondents considered use of lead aprons optional. CONCLUSIONS: Although the pediatric dentists surveyed believe they are in compliance with ADA-AAPD guidelines, most are unaware of IGCD recommendations. Use of digital radiography is almost ubiquitous, but use of rectangular collimation is limited. PRACTICE IMPLICATIONS: Dentists treating children should be familiar with ADA-AAPD radiation exposure guidelines and should consider using the dose-reduction strategies recommended by IGCD.

Patient motion image artifacts can be minimized and re-exposure avoided by selective removal of a sequence of basis images from cone beam computed tomography data sets: a case series.

This case series describes a reconstruction method applied to a cone beam computed tomography (CBCT) projection data set that used selected basis projection images to improve diagnostic image quality for patients who moved during the radiographic procedure. Reconstructed volumetric data from 6 patients at 2 institutions initially exhibited characteristic double contour images as a result of motion artifacts. For each case, the CBCT basis images from the entire projection data set were displayed as a cine sequence, and patient movement was identified during the first or last 90-degrees of a full 360-degree acquisition trajectory. Employing a useful reconstruction function of proprietary software, a secondary reconstruction was performed by discarding data acquired during the first and last 90-degree rotation. For all cases, this method provided a volumetric data set without motion artifact. General practitioners can apply this clinical method, whenever appropriate, to avoid a rescan and keep patient exposure "as low as diagnostically acceptable."

Linear accuracy of cone beam CT derived 3D images.

OBJECTIVE: To compare the in vitro reliability and accuracy of linear measurements between cephalometric landmarks on cone beam computed tomography (CBCT) 3D volumetric images with varying basis projection images to direct measurements on human skulls. MATERIALS AND METHODS: Sixteen linear dimensions between 24 anatomic sites marked on 19 human skulls were directly measured. The skulls were imaged with CBCT (i-CAT, Imaging Sciences International, Hatfield, Pa) at three settings: (a) 153 projections, (b) 306 projections, and (c) 612 projections. The mean absolute error and modality mean (+/- SD) of linear measurements between landmarks on volumetric renderings were compared to the anatomic truth using repeated measures general linear model (P < or = .05). RESULTS: No difference in mean absolute error between the scan settings was found for almost all measurements. The average skull absolute error between marked reference points was less than the distances between unmarked reference sites. CBCT resulted in lower measurements for nine dimensions (mean difference range: 3.1 mm +/- 0.12 mm to 0.56 mm +/- 0.07 mm) and a greater measurement for one dimension (mean difference 3.3 mm +/- 0.12 mm). No differences were detected between CBCT scan sequences. CONCLUSIONS: CBCT measurements were consistent between scan sequences and for direct measurements between marked reference points. Reducing the number of projections for 3D reconstruction did not lead to reduced dimensional accuracy and potentially provides reduced patient radiation exposure. Because the fiducial landmarks on the skulls were not radio-opaque, the inaccuracies found in measurement could be due to the methods applied rather than to innate inaccuracies in the CBCT scan reconstructions or 3D software employed.

In practice: how going digital will affect the dental office.

BACKGROUND AND OVERVIEW: The impact of digital imaging on dental practice depends upon the degree of planning conducted before implementation. Digital technologies have the potential to improve diagnosis; facilitate patient treatment procedures; and streamline storage, transfer and retrieval. These technologies also provide for secure backup of patients' image data, critical to re-establishing the practice should fire, flood or earthquake occur. CONCLUSIONS: The decision to invest in digital radiographic equipment should be a simple one for dental practitioners. Although digital x-ray sensors have long equaled analog film for diagnostic tasks, they have several advantages over film radiography, including immediate image production with solid-state devices; interactive display on a monitor with the ability to enhance image features and make direct measurements; integrated storage with access to images through practice management software systems; security of available backup and off-site archiving; perfect radiographic duplicates to accompany referrals; security mechanisms to identify original images and differentiate them from altered images; the ability to tag information such as a patient identifier, date of exposure and other relevant details; and interoperability of the Digital Imaging and Communications in Medicine file format. CLINICAL IMPLICATIONS: Most clinicians should contemplate integrating, at a minimum, intraoral digital x-ray sensors and a digital panoramic system into their practices.