The open book Issues in Contemporary Orthodontics gets published today and with it, chapter 9, which covers 3D surface scanning for intra and extra oral images (3D impressions and 3D photographs) as well as 3D printing technology and how it could affect the orthodontic practice.

The chapter is called 3D Scanning, Imaging, and Printing in Orthodontics, has been written by Emilia Taneva, Budi Kusnoto and Carla A. Evans and is available directly from the publisher's website, or downloaded here.


When orthodontic practices go paperless, the question of resolution arises: what is the best resolution to scan documents? Rumors say that 300 DPI is the level that is suggested on-line for preservation of materials which will be destroyed but need to be maintained from a legal perspective. However, this resolution produces large amounts of data and can eat up drive space quickly.


The recommended resolution for 2D Cephalogram X-Rays is 12bit grayscale (ca 4k shades of grey) and 300DPI scanning resolution. This is based on published studies, that state that below this resolution, the identification of landmarks becomes less reliable. However, this is crucial only for x-ray which need to be measured, i.e. cephs and, in some rare cases, postero-anteriors. For all other x-rays, the minimum resolution to get the job done can be much less because the job gets usually done by simply looking at the radiograph, without taking any measurements.
In any case, i would avoid BMP: they can get extremely large and slow to manipulate. DICOM would be the way to go. But if that's not an option, a high-quality JPG works great too: It can provide some compression, while keeping the images usable.


While 150 DPI is enough for practical usefulness (in other words, for being able to read and understand all information which was present on the paper version of the scanned document) of maybe (i'm guessing based on my personal experience) 90% of printed material, 300 DPI will make a difference if one wants to OCR the scanned documents, or for those 10% of documents which have a very fine print. I have no idea about the legal perspective.
However, one would expect a modern database system not to have any issues with 300DPI scanned PDF files. I would personally therefore keep scanning at 300DPI, and upgrade storage solution/practice management server to a 1 or 2TB drive. A 2TB should allow an average of 180MB/patient, for 10k patients. That's about 20 9MB images (very high 300DPI xray or other). And in a few years, when they start getting close to the 10k patients, the practice probably upgrade storage to 10TB or so.

See Also


On August 15th the AAO Bulletin published an article discussing the importance of establishing what medically necessary orthodontic care actually means. This has become crucial, ever since the Affordable Care Act (ACA) introduced benefits for orthodontics as part of the embedded pediatric (dental) medical policies... only available to those patients whose cases are considered to be "medically necessary".

See article below.

DICOMweb Hands-on Workshop

DICOM will hold the DICOMwebTM Hands-on Workshop, scheduled September 10-11, 2015, in Philadelphia PA. This could be a very cool workshop.

See Also

We are moving forward on our effort to provide a document that can explain developers/vendors how to exchange a set of images in a specific layout using DICOM (i.e. Structured Displays). So say provider provider A wants an opinion from provider B: A will send clinical data (with a set of images) and will expect B to be able to see the images in the exact same layout that A sees them, as this will simplify the collaboration. Thanks to DICOM Structured Displays, this will be possible even:

  • by sending all images with relevant information, such that the receiving system will know what they are and where to store them.
  • without creating a static composite PDF or JPEG file, with all the images inside.

So the ABO (American Board of Orthodontists) already defined a standard layout for their board exams. But that was just one layout. We are defining 3 layouts (which will serve as examples for the documentation), and are asking the ABO if we can call them ABO-01, ABO-02 and ABO-03.

 The ABO (American Board of Orthodontists) already defined a standard layout for their board exams. But that was just one layout. We are defining 3 layouts (which will serve as examples for the documentation), and are asking the ABO if we can call them ABO-01, ABO-02 and ABO-03.

ONC Privacy & Security Guide

The Office of the National Coordinator for Health Information Technology has released in April version 2 of the Guide to Privacy and Security of Electronic Health Information. Here's an excerpt from their website:

Need help implementing the Health Insurance Portability and Accountability Act (HIPAA) Privacy, Security, and Breach Notification Rules in your health care practice? Check out the Guide to Privacy and Security of Electronic Health Information [PDF - 1.27 MB].

The Office of the National Coordinator for Health Information Technology (ONC), in coordination with the U.S. Department of Health and Human Services (HHS) Office for Civil Rights (OCR), created the Guide to help you integrate privacy and security into your practice. The Guide covers a variety of topics highlighted below. Download a pdf of the full Guide [PDF - 1.27 MB] to learn more.




Information blocking occurs when persons or entities knowingly and unreasonably interfere with the exchange or use of electronic health information. This report focuses on potential information blocking by health care providers and health IT developers, including vendors of EHR technology. 

Here's the April 2015 report from the Office of the National Coordinator for Health Information Technology (ONC) to the US Congress explaining the obstacles to implementing interoperability and informatics standards.  The federal government has spent $28 billion on health IT and Congress wants to know the details of information blockage.

This report (see link below) from ONC to Congress was discussed at the April 21 meeting of the Illinois Health Information Exchange Advisory Committee.  The gist of the discussion was that the pilot studies on EHR interoperability have been excellent, but further progress will be difficult due to the reluctance of vendors and stodgy institutions to adopt existing informatics standards, especially HL7 standards. The Chair likened the situation to selling cars, saying that the states will have to mandate features that software must have in a manner similar to emission standards for cars. Our dental software vendors are lagging also.

The DICOM Editor, David Clunie informs that the 2015b release of the DICOM standard is now available from the NEMA ftp site:

It is also indexed from the DICOM Editor's status page at:

This replaces the 2015a release.

Release notes are at:

The changes from the 2015a release are shown highlighted in PDF files; note that changes to figures are not detected and some changed figures are not rendered in the diff files:

Apple announced the healthkit recently. A dive into the medical world. The idea is simple even though there has been an explosion in the number of mobile fitness apps which aim to track everything from food consumption to blood sugar levels, there was no way for doctors to get that information. HealthKit aims to bridge that gap by connecting medical providers and medical researchers with that health data.

The move is exciting, however, will Apple make use of an existing medical informatics standard? Is the Apple Healthkit making use of any existing medical software standard?

As far as i can tell, they are not. Apple's trend is to re-invent and come up with better ways of solving problems.

The purpose of the Healthkit, appears for now to be research only. It sounds, though, as if it could become the leading medical information exchange system. Similarly to what happened with ApplePay, Apple might come up with an easy way for a patient to send their clinical records to a provider, maybe even through an AppleWatch, and it most likely won't be using HL7 FHIR! Hopefully there will soon be bridges out there. Even with bridges, HealthKit doesn't model the medical field to the extent HL7 does, not even remotely.

It's just that the thought that Apple could be, possibly, maybe the future of medical informatics standards scares me. But then again, it most likely will not be...

See Also

Orthodontic Products (12/19) reports, “The American Association of Orthodontists (AAO) Board recently met in St Louis and approved policy language on medically necessary orthodontic treatment.” Orthodontic Products reports that the AAO “will support bifurcated policy structure characterized as traditional orthodontic cases and medically necessary orthodontic cases, to include the use of diagnostic codes (SNODENT or ICD10) in lieu of diagnostic indices.” Additionally, the AAO “will call for universally accepted diagnostic records (intra-oral and extra-oral photos—panoramic image and lateral ceph) for claims submission” and “will support the use of auto-qualifiers to determine medical necessity rather than more subjective indices; and will advocate for higher reimbursement for medically necessary cases.” 

At today's DICOM WG22 (DICOM in Dentistry) meeting held at the Radiology Society of North America at McCormick, the ADA SCDI told us that the ADA has funds to hire a consultant for the technical DICOM aspects of the visible light project dealing with images and templates.

A Structured display is a view of various images at once. The intent of this standard is to allow for various entities to share a set of images, and be able to all seem laid out the same way. An application could be, for example, the ABO board exams: the student could submit the images in a specific DICOM template, which he or she could generate with any DICOM compatible application that would support such functionality, which, hopefully at some point, most orthodontic software package would support.

DICOM is reviewing a correction package (DICOM CP14_XX: Radiation attributes to X-Ray 3D CRANIOFACIAL Image IOD) in order to be able to store more radiation based information along with the image for 3D craniofacial images. This has been submitted by Andrew Casertano for review by the DICOM WG 22 and discussion.  The review will take place on 2014-12-03.

This is an interesting work by a Brasilian team, which proves as a great implementation of HL7 v3. 

I think this could be a great read for those interested in implementing HL7 and integrating it with existing non-HL7 software. 

Comment Deadline: June 7, 2014
The following drafts are currently being circulated for all interested parties review:
Proposed ANSI/ADA Standard No. 27 Polymer-based Restorative Materials
Proposed ANSI/ADA Standard No. 119 for Manual Toothbrushes
Proposed ANSI/ADA Standard No. 128 for Hydrocolloid Impression Materials
Proposed ANSI/ADA Standard No. 136 for Products for Tooth Bleaching
Proposed ADA Technical Report No. 1030 for Dental Providers Guide to the Electronic Dental Record
Proposed ADA Technical Report No. 1041 Content of Electronic Laboratory Prescription
Proposed ADA Technical Report No. 1043 for Use of Computer-based Resources for Access to Information Supporting Oral Health Care
The scopes of the proposed documents may be found by clicking on this link.
To obtain copies of the complete documents, please send an e-mail message with your request to or call 800-440-2500, ext. 2506.
Please submit your comments using the template provided in the links above and submit by e-mail to, by FAX to 312-440-2536, or mailed to the Department of Standards, American Dental Association, 211 E. Chicago Ave., Chicago, IL 60611.
Thank you.
Kathy Medic
Manager, Dental Materials Standards
Standards Administration
American Dental Association  211 E. Chicago Ave.  Chicago,  IL 60611

Integrating the Healthcare Enterprise (IHE) is an initiative which promotes the use of established standards such as DICOM and HL7. Basically, they provide a testing framework against which developers can test their DICOM and HL7 implementations to see if it works. And then, they organize these big LAN (i.e. geek) parties in basements of hotels, where different companies (minimum 3) send 2-3 of their developers with a bunch of laptops and network cables to connect with each other and send files to each other to see if it all works. It's an awesome initiative, and it really shows how medical software standards are becoming always more requested and used!

IHE has already hosted a bunch of these LAN parties (Connectathons) around the world. However, in January 2014, they will hold the first one with the theme "Dentistry", or, more precisely SEDI: Secure Exchange of Dental Information.