DICOM Awareness of Oral and Maxillofacial Radiologists in India

Abstract

Since the late 1970's, diagnostic images have been increasingly in digital form creating a need for digital interoperability, something that was hithertofore universally achieved for analog images using transmitted light from a view box. The picture archiving and communications system (PACS) helped digital image management at a department or hospital level [1–6]. To have interoperability between devices, a single formatting standard was desirable, though initially a hardware solution had been sought. Digital imaging and communications in medicine (DICOM) is the International Organization for Standardization (ISO)-referenced standard for communication of diagnostic images and associated data. It is the internationally accepted format in which radiologic images are sent from scanners and digital X-ray devices, as well as the protocol used to send, archive, and retrieve them. DICOM has its roots in the USA from the American College of Radiology/National Electrical Manufacturers Association (ACR/NEMA) standard versions 1 and 2, developed in the 1980's, that were replaced in the early 1990's by DICOM “version 3,” the only version that has ever existed in DICOM [7]. In the mid 1990's, the DICOM Standards Committee was expanded from NEMA and ACR to include several dozen vendors, user groups, and interested parties. It had often not been possible to display digital images made using one proprietary system with another vendor's display software. Even different generations of the same manufacturer's imaging system have demonstrated incompatibility. This may well be the reason why full implementation of the filmless oral and maxillofacial radiology department or imaging center lagged behind initially, especially. While the American Dental Association (ADA) joined the DICOM Standards Committee in 1996, a working group specific to dentistry (WG 22) was only initiated in 2003. Indeed, the ADA only accepted DICOM as the means for interchange of images by resolution in year 2000. The ADA has now been joined by the American Academy of Oral and Maxillofacial Radiology and the American Association of Orthodontics giving dentistry three votes at the DICOM table. To protect the oral and maxillofacial radiologists' investment in equipment and the patient's investment of time, money, and radiation exposure, it is desirable to use a standard that will make digital radiographic images at least as durable and portable as their analog predecessors [8]. Though the adoption of the DICOM standard is voluntary, its use is international in scope [9]. DICOM has been adopted as a worldwide standard by such bodies as the ISO, as well as the European Committee for Normalization CEN TC 251 (CEN Technical Committee) for the European Standard MEDICOM. The Japanese Industry Association for Radiation Apparatus standard, Medical Imaging Processing System, is also based on DICOM. [10] However, the Indian Society of Oral Medicine and Radiology has not yet adopted DICOM as the standard for imaging. In the oral and maxillofacial radiology setting, patient diagnostic images typically include intraoral radiographs (periapicals and bitewings), panoramic radiographs, cone beam computed tomography (CBCT) scans, multi-slice computed tomographic (MSCT) scans, magnetic resonance images (MRI), nuclear medicine scans, and ultrasound. Oral and maxillofacial radiologists often refer images to their counterparts nationally and internationally for second opinions and also receive images from their colleagues and non-specialists to interpret. Digital image communication is unlikely if two practitioners use divergent imaging system or software or both without using a compatible format, namely, DICOM. The same problem can also be encountered within a single office using digital image acquisition systems from different vendors or even just different generations of detectors or software from a single vendor. Most manufacturers of digital dental imaging equipment are now seeking to become DICOM conformant; however, progress in this direction is less advanced in India. With the continual introduction of many new image acquisition systems, a standard for exchange is becoming even more important for portability and accessibility of dental diagnostic images. Though DICOM is not absolutely needed for interoperability, given the fact that DICOM standard that has already been developed, it would be unreasonable to redevelop a separate standard for digital dental imaging systems [8]. There are presently 1,332 oral and maxillofacial radiologists registered with the Indian Academy of Oral Medicine and Radiology, most working in oral maxillofacial radiology units of dental schools, with others working in private practice, largely in imaging centers [11]. The oral and maxillofacial radiology practice in India generates substantial numbers of radiographic images and can benefit from use of the DICOM standard as a means of promoting interoperability as these images are usually made for referred patients, with the images needing to be sent to the referring practitioners. In spite of the known effectiveness of the DICOM standard and the increasing availability in India of X-ray equipments using DICOM, there are still misunderstandings on the benefits of DICOM and the real impact of DICOM on the images [7]. In view of the current confusion in the use of DICOM in the practice of oral and maxillofacial radiology and the relative dearth of literature on the awareness of DICOM by Indian oral and maxillofacial radiologists, it was decided to assess the use, awareness, and knowledge of DICOM by this group.