Scott D. Benjamin, DDS
All technologies used in dentistry must either enhance the quality of patient dental care or improve practice efficiency. Digital photography is a technology that can do both. However, like all technologies, its use must be appropriate and properly implemented.
The goal of any practice that adopts digital photography should be three-fold:
1To manage the technology and associated processes efficiently, so that they don't add overhead costs to the practice;
2To utilize the technology in such a way that it will boost case acceptance, thereby increasing revenue; and
3To use the technology to improve outcomes, which can both reduce costs (for example, by reducing remakes) and increase revenues (through, for example, generating positive word-of-mouth feedback).
The right digital camera
One of the reasons digital photography is such a good fit for the practice of dentistry is that, compared to film, it offers inherent efficiencies. With digital photography, you can tell immediately whether or not you've captured an image of sufficient quality. If the image is blurred, or framed incorrectly, or lit improperly, you can immediately retake the image. With film, mistakes often are discovered after the film has been developed. Retaking the shot may require the patient to return to the office.
Digital photography also makes it easy to produce multiple prints of digital photographic images on an inkjet printer. With a few mouse clicks, you can create prints and send them to referring specialists, physicians or other third-party recipients. With film photography, you have to either duplicate your prints or part with your copies and hope they'll be returned.
Digital photography also lets you automate the tracking of images. Instead of having negatives or prints that must be physically filed with patient records, digital photographs are stored in computer databases. When you want to see a particular patient's images, the computer tracks them down for you. Your staff doesn't spend time filing and refiling negatives or prints ... or hunting for the prints.
While digital photography is an efficient technology, not all digital cameras are equal. I've tried over a dozen different digital cameras in my practice, and found a huge variation in ease-of-use, color accuracy, and other factors that influence efficiency.
Today, we're using the Kodak DX4900 Dental Digital Camera Kit. It's by far the best-suited to dental photography than any other digital-camera setup we've used for several reasons. First, the camera comes with built-in distance and framing guides. These ensure that views are properly framed and taken at the proper distance, helping to reduce the need for retakes.
In addition, the camera kit comes with the Kodak EasyShare Camera Dock II. This is a computer peripheral device that attaches to a PC with a USB port. When you seat the camera into the docking station, it does two things: 1) It recharges the camera and 2) it lets you transfer images from the camera's internal memory to the computer with the press of a button.
In our office, we keep the camera on the docking station when it's not in use. The battery that powers the camera and its internal flash is always charged and ready to go. This is a huge improvement over other digital cameras when it comes to efficiency — we no longer find ourselves having to switch batteries halfway through photographing a patient. We also don't have to worry about whether we have fresh, charged batteries on hand. The docking station takes care of that for us.
In addition to eliminating the need to manage batteries, the docking station also eliminates the need to manage image storage cards. Images are transferred off the camera to our computer network each time the camera is returned to the docking station. We always know we have plenty of room on the camera for the next series of images. Just as we're no longer juggling batteries, we're no longer juggling memory cards.
The docking station has also improved our ability to manage our photography protocols. When the camera is not in use, it's kept on the docking station. As a result, everybody always knows where the camera is when it's needed.
In the past, we often needed to keep three or four cameras in circulation in my office, just to make sure that there would be a camera available, with a charged battery and room to store some pictures. Today, we do the same amount of photography-sometimes as many as 25-30 images of a patient in one appointment-with a single camera.
The right photographers
In addition to choosing the right camera, it's also important to put it into the right hands. Taking photographs does take time. So you need to ask whose time is least expensive to your practice.
There always will be a few occasions when it makes the most sense for the dentist to take the photographs. But in the vast majority of cases, it is better for the auxiliary staff to handle the photographic workload. The reason is simple. In most practices, the dentist's hourly billing capacity is a minimum of four times that of what the auxiliary staff's services can command. As a result, when the dentist spends time on activities that are not billable, the practice's bottom line is affected far more than when auxiliary staff spend time on nonbillable activities.
Sometimes I want to document procedures as I do them. Even in this case, it's often more efficient to have the chairside assistant capture most of the images while I am performing a hygiene check or administering anesthesia to another patient. A workflow pattern such as this means there is no additional chairtime required for the photo documentation. If my time is not required with another patient, then I will assist the auxiliaries in capturing the images to help expedite the process.
Photography also can raise practice revenues. But those gains can be negated if the dentist, instead of the auxiliary staff, is the one taking time to use the camera. Conversely, if you want to maximize the fiscal benefits of digital photography in your practice, make your auxiliary staff responsible for taking the pictures.
Training and protocols
It sounds obvious, but one element of efficiency that practices shouldn't overlook is ensuring that the auxiliary staff knows how to use the camera. Mastering the camera will reduce the number of retakes. It also will increase the staff's comfort and confidence in taking quality images, and it will help them fully leverage the camera's capabilities.
Good digital cameras, like any good electronic device, should come with simple, easy-to-use documentation. A simple, straightforward manual is vital for learning and understanding the camera and its role in dental photography. In addition, the manual should function as a quick and easy reference guide for the camera and attachment-settings.
Another important aspect of dental-digital photography is to establish photography protocols. Every practice needs to determine what views are going to be taken, of which patients and procedures, as well as when and where the photographs will be taken.
Many protocol issues are a matter of common sense. Some can be figured out even before you start using the camera, based on how patients are directed through the appointment process. In other cases, photography protocols will evolve as you and your staff become more fluent with your camera and how you use your images.
Even as your protocols change from time to time, they need to be standardized as much as possible. When protocols are followed, they eliminate mistakes and guesswork ... and that improves efficiency.
In my practice, we have clear protocols guiding the photo-documentation process. While these protocols are clear, they also are flexible. For example, we don't always take images of a patient at the same point in all appointments. It depends on the patient, the reasons for the patient's appointment, and workflow issues. The key elements of our protocol are:
1) We know what photographs we need for particular treatment scenarios.
2) We track which patients have been photographed, and which have not. Our motto is, "When in doubt, take the shot!" We have found that it is usually faster and more efficient to capture an extra image than to have the auxiliary interrupt the doctor while he is doing a procedure on another patient.
If a patient comes in for a hygiene visit and requires nothing more, our hygienist may take a shade-matching photograph at the end of the appointment. This photograph frequently will be used for nothing more than to raise the patient's awareness about our practice's whitening services.
If the hygienist discovers a problem during the appointment, such as a cracked tooth, she will take a photograph or series of photographs of the patient's problem area, assuming there is time to do this. These photographs may form the basis of our future treatment-planning, including cosmetic simulations, particularly if the problem is in the bicuspid or the anterior region.
Both of these examples assume that the hygienist has finished the routine procedures and I have not yet arrived to perform my clinical check. But what if I arrive before the hygienist has had a chance to take any pictures? In this case, it depends on the office workload and how busy we are. If we have time to keep the patient in the chair after my exam, the hygienist or another staff person will take the photographs then.
In some cases, we wait to take our photographs at the beginning of the patient's next appointment. Another point at which we often take photographs is after I've administered an anesthetic. While I wait for the anesthetic to take effect, my staff has an opportunity to take a series of photographs. In both of these cases, we have flagged the patient's record with a note that photographs were not taken during the initial appointment. So at the time of the follow-up appointment, staff members know they need to work in some photography at some point.
Another potential situation is a patient who wants a complete cosmetic makeover. In this case, we set aside time to take a full set of views. This is, however, the only instance in which we dedicate time specifically to photography.
From camera to computer
Once images of a patient are captured, the next step is to transfer them to a computer and import them into an image-management software application such as PracticeWorks-DICOM Imaging Software or Image FX from SciCan.
This is a procedure that must be automated as much as possible. If it isn't, a dental practice can easily become bogged down in tracking, naming, and cleaning up image files. Fortunately, with the use of a camera-docking station and the appropriate software that is available today, transferring digital-camera files can be made fast and easy.
In our case, we have configured our camera and computer network so that the entire transfer process takes only seconds. After an image or image series is captured, the camera is placed back on the docking station, which is tethered to one of our computers. By pressing a single button on the docking station, the EasyShare software residing on the computer is launched.
The software automatically creates a shared-networked subfolder that is titled with that day's date (e.g., Z: Camera Images 2003-02-06). It then saves the images to that folder. At the same time, it transfers the images, the software also removes the copies of the images that reside on the camera's memory card, so the camera is now ready for the next patient.
As the files are saved to the network drive, each image is automatically given a unique numerical name. From any computer on the network, the staff now can view the images and transfer them to the patient's electronic clinical record, which we maintain using PracticeWorks-DICOM Imaging Software. With this software, the original copies of the image are automatically removed as well, so we never have to manually clean up duplicates.
At this point, the images are part of the patient's clinical record. They can be used in any manner appropriate to benefit the patient's treatment plan. In our practice, we use images to assist in discovery and diagnosis, and to aid in patient education and codiscovery of problem areas. Depending on the patient, the planned treatment, or other factors, we also may forward copies of particular images to specialists, prosthetic labs, pathology labs, or insurance carriers.
This is the point that the value of the captured images can be leveraged for practice-building and boosting standards of care.
Care and case acceptance
Using digital photography efficiently helps ensure this technology won't have a negative impact on a practice's bottom line. What I've found, however, is that digital photography increases case acceptance, while improving my standard-of-care at the same time.
An excellent example is in the case of soft-tissue abnormalities. Every year, some 30,000 U.S. citizens are diagnosed with some form of oral cancer. Yet, as many dentists realize, the public has little understanding of our ability to screen for oral cancers. In the past, I often encountered patients with suspicious lesions who simply didn't take this concern very seriously. They assumed my expertise was in teeth, not cancer.
All of this has changed since I started using digital photography. Today, any time we see an oral lesion, we photo-document it. When patients realize a lesion is important enough to photograph, they take it more seriously. This has had an enormous impact on my patients' acceptance of my treatment recommendations.
For example, if I suspect a lesion is cancerous, I typically recommend immediate biopsy. If I feel a lesion is benign or of an inflammatory nature, we have the patient return in approximately two weeks for a follow- up exam, at which time we perform some additional photo-documentation of the area and any appropriate treatment.
Since I started photographing lesions, virtually every patient for whom I have recommended a biopsy has accepted the recommendation. The percentage of patients who comply with follow-up exams also has risen substantially. My patients also are more likely to follow through with the appropriate treatment. Needless to say, this has had an enormous impact on my practice's standards of care.
Digital photography also boosts standards of care in purely practical terms. To continue with the example of soft-tissue pathology, after we photograph a suspicious lesion, we provide both electronic and print copies of the images to my pathology lab. We email the digital copies immediately! This gives the pathologist an opportunity to become familiar with the case before the microscopic evaluation of the biopsy tissue is conducted. Then, when we ship the tissue sample, we enclose my description of the lesion and a print of the discovery, both pre-operative and post-treatment. To create my prints, I use a color inkjet printer and print on Kodak Dental- and Medical-Imaging Inkjet Paper. This is a photographic-quality, glossy paper that gives excellent color rendition and detail. Including a print is critical — it gives my pathologist the ability to confirm that the digital images are with the correct case and allows him to view the lesion's clinical appearance while at the microscope, which aids in the diagnosis.
My pathologist typically returns digitized, microscopic images with the biopsy reports. I then import them into the patient's electronic clinical chart to keep the records complete.
Before and after
Digital photography also is ideal for helping patients visualize the benefits of aesthetic and restorative procedures. Dentists can take images of a patient's smile and, with a little digital-editing, show the patient how he or she would look with whiter, brighter, or straighter teeth.
Another option is to display images of comparable cases. In my practice, I maintain a library of cases for this purpose. These cases show how my treatments have helped people improve their smiles. My "before" images help a patient remember how they looked before provisional restorations were placed. The "after" photographs help my patients visualize the restorations more accurately, so they truly can appreciate the benefit and value of their dental-health investment. Using digital photography in this way can help boost case acceptance for aesthetic procedures.
Improving outcomes
Another way digital photography can strengthen a dental practice is by improving outcomes. For example, using photography to enhance communications with prosthetic labs can reduce the number of remakes. This can have an enormous impact on a practice's profitability, because every redo can potentially double the overhead cost of a case. By giving the lab more information about the patient's tooth shades, shape, and other characteristics, digital photographs help ensure that the first prosthetic will be a perfect match.
As with providing images to pathology labs, it's best to provide images to prosthetic labs in both digital and hard-copy form. This maximizes the benefits of the digital-photography technology. The digital copy lets the technician enlarge and enhance the image if they desire. The hard-copy print accommodates technicians who (as is often the case) do not have computers near their workbenches. When you provide a print, they have an image that they can mount in the work area to view it as they build the prosthetic.
Last, but not least, higher standards of care and improved outcomes lead to higher patient satisfaction and more word-of-mouth referrals. By using photography to simulate restorative procedures, my patients are happier after the procedure is complete. They know what enhancements the procedures can achieve, and I know they will be happy with the results.
