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Exceptional Clinical Photography: Putting It All Together--Part 3 of 3

Dec. 1, 2007
My previous two articles covered why one should capture and present high-quality digital images to patients, and the tools necessary to do this.
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by Glenn D. Krieger, DDS, FAGD

My previous two articles covered why one should capture and present high-quality digital images to patients, and the tools necessary to do this. If you read the articles, you learned that getting involved in “digital co-diagnosis,” which provides considerable benefits to both patients and practice, is not something that can be jumped into without some preparation. My goal is to pull together the physical and emotional components of this process so that readers can implement these techniques with predictability and success.

As a practicing clinical dentist, I can appreciate incorporating new technology into my practice. It should be as simple as possible to integrate and use, and it should have a reasonable return on investment. If you’re like me, you can probably appreciate the KISS (Keep It Simple, Stupid) principle as it relates to changing things about your practice. I want to do it right, but in the straightest line possible. That’s how I integrated the digital co-diagnostic process into my practice, and I’ll try to help you make the transition from using zero or limited imaging to becoming a master of digital image capture and work flow.

Although some experts would have you believe that this process is laden with a massive amount of technical information, from a user-friendly standpoint it really isn’t that tough to understand. Don’t be scared off by this amazing and powerful approach to case diagnosis and presentation. It really can be very simple, but like learning how to prep a simple Class I restoration, there is a learning curve, and it will take time.

I’ve said it before and it bears repeating; if you want to capture exquisite images with minimal difficulty while watching case acceptance increase considerably, attend a hands-on course about how to implement the technological and photographic components of the work flow. I believe that the proper clinical skill related to capturing images is far more important and challenging than mastering the software aspects of digital diagnosis and case presentation.

A good course should include “loaner” cameras so you can determine which system is right for you, and should emphasize the proper clinical technique for getting those “tough” lateral arch or full occlusal images. Once you master capturing images, learning the software for the rest of the process becomes considerably easier and quicker. Do not buy a camera on someone’s recommendation without first taking some hands-on clinical photographic training. You may learn that the camera you bought prior to training just doesn’t do what you want it to do once you learn how to capture great images.

When new patients enter my practice, I like to meet them in my consultation room before introducing them to the clinical setting. It’s great to spend even just 15 minutes with patients getting to know a little about them and why they decided to walk through my front door.

During this time a lot of very important information is shared, not the least of which is our practice philosophy. If I see something that makes me think this patient may need extra attention, I touch upon study casts and images as a normal part of my diagnostic process. I’ve found that mentioning this early in the relationship is a low-stress, nonconfrontational way to let patients know that my practice may be a little different than others. Most of my patients, although they accept the need for diagnostic images, have never been through this process and need a bit of education about why we take these images as part of the diagnosis and treatment planning process.

Once the consultation and medical and dental histories have been completed, I escort the patient to the clinical setting, where I perform the new-patient exam in the way that I was trained. There are many schools of thought about what should be done during a comprehensive new-patient exam. If you are unsure, there are some amazing teachers and programs available around the country to show you.

In my practice, I use this exam to gather appropriate information to determine the next course of action. I’m not trying to comprehensively diagnose and treatment plan the debilitated dentition in an hour, but rather decide what should come next for this patient.

If the patient has no decay and a beautifully treated Class I occlusion, or a couple of Class I restorations in need of replacement, I discuss my findings and arrange a hygiene appointment. However, if the patient exhibits occlusal breakdown, soft-tissue-related problems, more than basic restorative needs, or any other issue requiring extra attention, I explain why I feel it is necessary for him or her to have diagnostic casts and images. When explained as a necessary step to the diagnosis and treatment plan of the oral condition, nearly every patient agrees to return for the “records” visit.

When the patient comes back for records procurement, I review why I believe this information-gathering stage is important. Because taking impressions for study casts can be a bit a messy, I like to capture the images first.

At my hands-on courses, my students and I often engage in a philosophical debate about whether images should be captured by the dentist or delegated to a staff member. Although I believe that assistants are capable of capturing beautiful images once properly trained, I don’t delegate image capture to anyone in my office for several important reasons.

There are often small nuances to a case that may play a larger role, and these need to be captured in our images in such a way that we can better understand what roles they play in the treatment plan. For instance, if the interpupillary line or smile is significantly different than normal, one may want to capture that aspect in more detail, and it is very important that the data be captured with the utmost accuracy. Sometimes it is our dental training that helps us spot these issues, and if delegated to the assistant, the necessary data may be incorrectly documented or missed.

Another reason I do not favor delegating image capture to auxiliaries is because this is the first meaningful clinical interaction that the patient will have with my practice aside from the initial exam. I’m working in his or her mouth, but I’m not using a rubber dam or performing an invasive procedure.

It’s a wonderful way to have a “first” clinical interaction, to get to know the patient in a low-stress clinical situation, and still not be doing anything irreversible. I often learn a lot about the patient’s clinical temperament while capturing images. Some patients come through the process easily and others exhibit behavior that indicates treating them later may be challenging.

During the image-capture phase, there are typically 11 shots that I take for a standard set of images: full-face smiling, full-face repose, full-face profile, up-close smile, up-close repose, lips retracted closed, lips retracted open, left lateral, right lateral, complete maxillary arch, and complete mandibular arch. It’s nearly impossible in one article to explain how to best capture these images, but I will touch upon a few of the major points I keep in mind while photographing patients.

For the full-face images, it’s important for patients to remove their glasses and hearing aids that wrap over the ear. I like the ears to be completely visible, so I ask patients to sweep their hair over their ears. You should also try to capture the information in such a way that accurate profiles and facial vertical angulations are properly recorded. Background color and texture are important, but I see too many teachers dwell on this subject for an inordinate amount of time, and I see a lot of stressed-out students worry about their backgrounds to a point of near insanity. Don’t sweat it so much.

As long as the background allows viewers to focus on the clinical information and not the background, and the patient’s face can be clearly seen in contrast to the background, things will be fine. I like using a dark taupe background because it contrasts nicely with almost every patient’s coloring, yet doesn’t become a separate component of the picture like, say, a blue background. If your goal is to capture artistically framed facial images, then I suggest setting up a simple photographic studio in your office, which will satisfy your desire to go beyond the basic clinical look. Last but not least, shadows around the patient’s face should be minimized for clear outlines of the facial edges.

The up-close smile and repose images should show lips and teeth and nothing more. The corner-to-corner smile should fill the entire width of the frame and be captured prior to the repose image. If you need to view the smile related to the rest of the face, you will have that information in the full-face images. The up-close images are solely to look at the smile and repose information as it relates to the patient’s teeth, lips, and gingiva. Images should be taken at the same magnification and settings so that when compared side by side, you will be able to easily evaluate lip mobility when the patient is smiling.

When capturing the repose images, have the patient say “Emma,” which puts the patient into an excellent repose position. There are other ways to get the patient to this position, but the “Emma” trick has produced consistent results for me. If you cannot see the incisal edges in repose because of wear or anatomical issues, place a perio probe on the incisal edge for the image so that you may determine where exactly the incisal edge is located related to the lips. It is often a vital piece of information for treatment planning.

The retracted closed and open shots are taken at the same magnification and settings. Capture the entire width of the arches, but no more in the frame. The biggest mistake I see my students make is taking the images from too far away.

As a result, the lips, cheeks, and retractors are often in the frame. I know that this sounds like a minor issue, but when taught properly, capturing just the teeth is no more difficult than an image that has additional and unimportant clinical information present.

The lateral images, when taken properly, provide some of the most important clinical information. In my practice, these images include the contralateral central incisor to the distal of the last molar, at 90 degrees to the arch. This final criterion is of vital importance. If the shot doesn’t demonstrate an image that is 90 degrees to the arch, then proper evaluation of the angle’s classification will be misrepresented.

Using the mirrors and modified retractors properly makes it possible to capture a perfect image nearly every time. However, it takes a lot of practice. Common mistakes include not capturing an image that is perpendicular to the arch, incorrect mirror angulations, and being too far or too close to the mirror. Proper hands-on training and repetition will ensure well-composed lateral images every time.

The complete maxillary and mandibular images are easy to capture as long as certain rules are followed. One should stand behind the patient for maxillary images and in front for mandibular shots. Keeping lips, retractors, noses, and tongues out of the image is vital. Moving the tongue out of the way is easy once you learn how to do it. Simply put, once the mirror and retractors are in proper position, ask the patient to place his or her tongue behind the mirror.

Most can do it easily, but for those who have difficulty, moving the mirror forward a drop will help them get their tongue in position prior to moving the mirror into final position. “Tongue-tied” patients may find it impossible to move the tongue out of the way, and that’s OK. Just do your best, and recognize that having the tongue in the image is the rare exception, not the rule.

One doesn’t have to be limited by the types of images I mentioned. In many cases I take 10 or 15 additional images, depending on what I am looking at. Creatively determine what best relays the vital images of the case so that you can learn as much as possible from the captured images. If you are working toward accreditation from a dental organization that requires specific images, be sure to consult their guidelines prior to capturing images.

Keep in mind that the aforementioned 11 images, when taken properly, develop an appropriate level of skill that once mastered, makes most accreditation protocols seem easy. I upload the images into my computer, edit when necessary, and present them to the patient at his or her third visit, using technology I discussed in previous articles.

Patients appreciate the detailed information captured in the images, and the power of the images to motivate them to higher levels of understanding and care should not be underestimated.

Just remember that this workflow and technology, though relatively easy to learn, don’t come naturally to most dentists and need to be practiced. Allow for adequate time when taking images for the first dozen or so cases, and don’t compromise or cut corners in your search for the ideal image.

Remember that most patients don’t have a hard time with the image-capture process, and the limitations and concerns we have are just that — our concerns, not the patients’.

Last year I was teaching hands-on photography to a study club, and after capturing a complete mandibular arch shot, my subject informed me that her staff had not been able to capture bitewing radiographs on her because of her gag response. Elderly and “gagger” patients are no more challenging than any other patients, so don’t treat them differently.

I hope this information will help you get started in what I believe is one of the best ways to take a practice to the next level. Seek out a way to implement the digital co-diagnostic process in your practice. Capturing and presenting images is the cornerstone in a method that has allowed me to work on fewer patients while performing more comprehensive care in a relaxed, slower paced environment. Our office has become as financially successful as ever, and our entire staff finds tremendous fulfillment in what we do.

Give it a try. Your patients will appreciate your unique approach to their care, and the partnership you create with them through the diagnostic and treatment processes will help make the practice of dentistry everything you ever wanted it to be.

Glenn Krieger, DDS, FAGD, is the director of the Continuum for Complete Care, which provides hands-on courses to teach dentists and staff how to use high-quality clinical photography as a diagnostic tool for comprehensive treatment planning and extraordinary practice growth. Dr. Krieger also lectures on clinical photography and “Digital Co-Diagnosis” as treatment planning tools. He practices in Seattle, Wash., with an emphasis on comprehensive treatment. For more information on his lecturing or courses, visit Dr. Krieger can be reached at [email protected]. His blog address is