Dr. Kunal Desai talks about the art of clinical photography and how it can enhance the way you practice dentistry.
Clinical photography is becoming a vital aspect of dentistry, are you taking full advantage of it?
How it all began
I have always had an interest in photography from a young age, from the time I received my first Canon digital camera for a holiday to the DSLR I now own. Photography is so important in capturing moments in life as a snapshot in time for memories to look back on, similarly we can use photography in dentistry.
“It shouldn’t take more than 3-4 minutes to take a full series of photos.”
Dental photography is becoming the norm for modern dentistry. Most people think that taking photos is time-consuming and that there is no room for it in a busy office, but learning to take the necessary photos and practicing continuously allows you to become faster. Once you have the kit, the photography accessories, for example, the mirror/cheek retractor/contrast, and your assistant has been trained to assist you, It shouldn't take more than 3-4 minutes to take a complete series of photos.
When I first started working in dentistry, I would swap out an amalgam restoration for a composite one and then show it to the patient while asking them “do you remember what your tooth looked like before?” With them constantly shaking their heads and saying no, then trying to explain what it looked like before and struggling to show them the new tooth in the mirror. After a while, it all became pointless. At the front of the mouth, the changes are easily noticeable – but how visible is a composite on the bottom of the left 7th tooth?
It took me a while to stop being lazy and start taking photos, first with a small digital camera – I only took photos of previous restorations and avoided taking posterior occlusal photos because a) I didn’t know how to do it b) I was too lazy to try c) I could never get the lighting or positioning consistent. But I didn’t realize that all I needed was a basic camera and a flash, an intraoral mirror and a retractor. Then the rest would come with practice.
Why is dental photography an integral part of dentistry today?
- Communication with the laboratory
- Documenting your work
- Critical evaluation
- Patient education
- Practice and self-marketing/portfolios
- lecture
- recommendation
- Treatment planning
- Monitoring conditions
What equipment do you need to take good clinical photos?
- DSLR camera body, e.g. Canon, Nikon
- Macro lens (100mm/ 60mm)
- Light source: Ring flash/double flash (owl mount)
- Cheek retractors
- Flexible contrasts
- Mirrors: buccal and occlusal
- Advanced: cross polarizing filter, bouncers
- SD card/WiFi compatible SD card
How does clinical photography improve your dental practice?
I strongly believe in learning from what you do, whether it's mistakes or not, there is always room for improvement and the ability to grow. As modern dentists, this is essential to providing an excellent standard of care.
Taking good clinical photos of your work allows you to to reflect on the cases and treatments you have done. Just as you would grade and evaluate a post-operative root canal radiograph; a similar ethos can be applied to clinical photographs. By taking a good pre-operative clinical photograph and then, from the same angle, a post-operative photograph, you can see flaws and areas that need to be adjusted or improved. For example, a bit of flash left after a posterior composite or corrections to line angles when finishing an anterior composite. These tiny details are sometimes missed by the naked eye even under a magnifying glass, but Macro photography is unforgiving and makes these tiny details stand out.
These tiny changes to your work make the biggest difference. This process allows you to learn and grow, and when you reproduce similar work, you discover these issues earlier and fix them, making your work time more efficient and the quality of your work much better. This way, you are able to produce more predictable results for your patients.
Evaluation of your activity
Critically evaluating your work also allows you to look back and see how much you have improved. Reflecting on one's work is an essential part of any dentist's ongoing development. It's amazing how, after we've finished that filling, we sit and admire it at that moment. However, when we look back a few years later, we realize how imperfect some things were. Whether it's because those line angles were slightly off, or because the shade wasn't quite right, or because the marginal ridge was too flat.
For many years I have been fortunate enough to have a good base of like-minded friends and colleagues to whom I can send my work for further evaluation and recommendations. It is essential to have this base, as sometimes you may not notice something that others might. In addition, it is essential to have a mentor to whom you can show your work for evaluation and advice. As a young dentist, it is essential to be open to constructive criticism and treat it as advice to improve yourself, to improve your skills.
The posterior composite photos above were not taken with a mirror and therefore we cannot see the tooth from the occlusal view, which is taken directly with a cheek retractor. These photos were taken to demonstrate the anatomy of the restorations. You can see how the first composite restoration has fairly flat cuspid slopes, while the second, more recent restoration is more tooth-like, with rounded aesthetic slopes and also some fissure staining to match the existing teeth. A friend told me about the more rounded slopes and cusps and that I might have been making them too flat. I took this into account and practiced creating more natural-looking restorations. Taking photos like this from a different angle allows you to evaluate your cases in more detail and always try to improve. Plus, it is a great way to show the details in your work.
The importance of educating your patients.
Taking these before and after photos and showing them to the patient is invaluable because dental problems are not always accompanied by pain, for example, a composite that doesn't work or a large amalgam with chipped edges and enamel/dentin fractures. I like to show my patients problems they have that they are not aware of and then show them after I have treated them. This is a great way to build a relationship with the patient and make them understand the procedures and techniques. In addition, simply showing a photo of a patient's teeth makes them see exactly what they have – normally this is a trigger for him to want to make some changes. Most patients will ask – is that in my mouth? Are those my teeth? And this normally leads to an acceptance of the treatment and also to improved oral hygiene.
Before and after a case of direct composite crown and veneer replacement.
The photo above (before surgery) – although taken without a macro lens, without a ringflash or twinflash; is able to present the patient with her smile and unsightly looking crowns, which do not suit either the patient or the adjacent teeth. The angle and focal point of the photo are not parallel to the patient, i.e. they are not parallel to the occlusal plane – taken from below the occlusal plane. The photo below (post-surgery) – the positioning and focal point are better, but the lighting is not. Therefore, there is a difference in the consistency of the photos, which makes it difficult to evaluate and reflect the case correctly.
Although these differences are not visible to the patient, they can make a big difference in results. This illustrates the importance of good reproducible illumination and consistent positioning.
“Reflecting on the work done is an essential part of the continuous development of any dentist.”
This case was my first smile remodeling case, from which I learned a lot by taking before and after photos. It also highlighted the need for smile design planning, which I began to do through direct-to-office mock-ups using composite, trial smiles based on lab mock-ups, and also digital mock-ups.
Before and after: Teeth whitening and 4 veneers with minimal preparation (2019).
This case is a more recent smile change. Compared to the example above, both photos were taken with a macro lens and a ringflash; producing more accurate photos, with similar lighting for both photos. This makes it easier for us to plan and evaluate the case.
Smiling patient photos are a great way for patients to see their smile up close. It also allows us to evaluate the smile and plan for improvement. In this case, we used a chairside mock-up: we placed composite on the lateral incisors to mask the rotation and incisal height, and distally to the incisal edges of the central incisors to make the front teeth less triangular.
I have also found it helpful to show patients side profile smile photos and then retracted intraoral photos straight on the photos, with an emphasis on the laterals.
Above are some useful side smile photos to take to show the patient what others can see when they smile or what the photos may look like when the patient smiles.
Simple photos of the patient’s smile can be taken for teeth whitening, in addition, retracted photos can be taken. Above are before and after photos with vita shade tabs to illustrate the color change. These photos are quick and easy to take and are very useful for showing patients the original and new color. These photos are quick and easy to take and are very useful for showing patients the original and new color of their teeth. I like to have the Vita shade guide set up in color order, from whitest to darkest. Here, the only important thing is to capture the same position – in line with the occlusal plane and capture the smile. Presenting the images side by side or one on top of the other makes it easier to show the difference. This can be done using several applications, for example Collage maker. For example, if we look at the cases below:
Before and after: Invisalign, whitening and composite bonding. You can see that the first photo shows a contrasting result – both photos were taken without a ring flash. You can see the shadows that appear in the photos at the back of the mouth and under the lip. Again, these differences can be seen in the photos below. The after photos, taken with a ring flash – there are no shadows.
Communication with the laboratory
Taking accurate and consistent photographs of the teeth before and after the tooth preparation with several shade tabs is essential. This is essential to show the lab what you are trying to reproduce. Shade matching and mapping can sometimes be difficult, and producing good quality photographs to the lab will help overcome some of the mapping difficulties. Examples: halos, translucency, opacity, fissures/stains, size and anatomy.
It is important to take photos of models and lab work before and after adjustment to help educate your lab and help improve their work. When the lab knows that their work is being showcased, it helps them evaluate their work and achieve excellent aesthetic results.
I try to ask my lab technicians for feedback on preparations, and you should do the same if you don’t already. Sometimes the blame is placed on our technicians when our preparations, impressions, or information didn’t help them. You can clearly see your preparations on the models and see areas that might need improvement, whether it’s the preparations or impressions. For example – smoothness, air pockets, undercuts, and sharp angles. Photographing the impressions and models shows these issues more clearly and allows you to recognize any potential problems.
Top down: Situation before surgery; dark tooth after root canal treatment, large composite. Second photo with darkening contrast. Fitting a crown after surgery with darkening contrast.
Emax crown on the model. Emax crown and model showing gingival margin integration. Laboratory work created by Pictodent Dental Lab.
Lab work showing 4 facets on the model. Above is the blackout technique and below is the whitewash technique. The photo below is taken to show the translucency of the facets. This is a great way to show off your photographic creativity and showcase your work at the same time.
Recommended practical photography course: F:OCUS by Minesh Patel – advanced techniques are taught in this course and is a must for all dentists.
What is the most important thing in photography?
Simplicity, consistency and reproducibility are the keys to taking good clinical or artistic photographs and taking your dentistry to the next level.
Top tips for everyday clinical photography:
- Get written and verbal consent for your photos – check the GDC regulations for posting on social media.
- Keep it simple and aim to take consistent photos, shooting from consistent positions and using the same focus points
- Educate your nurse and be prepared: Make sure all batteries are fully charged. Have all mirrors, retractors, and contractants ready. Make sure the mirrors are warmed in a water bath (you can use an alginate bowl) so they don’t fog up. If they do fog up, ask the nurse to blow air from the 3-in-1 device onto the mirror while it is in place.
- For flash batteries: buy rechargeable batteries and a charger.
- Make sure the object you are photographing is dry – tissue/ 3 in 1
- Apply Vaseline to patients' lips to make retraction more comfortable – or ask them to lick their lips
- Ask the patient to retract their lips and cheeks themselves after you have positioned the retractors – and guide them if you need to adjust them
- Use mouth mirrors for posterior photos, occlusal mirrors for full-arch photos.
- Remember what settings you made on the original photo so that when you take the post-op photo you can change the settings to have that important consistency. This can be recorded in the patient's notes.
- Buy some mirrors and retractors, as you may have consecutive cases.
- Keep taking photos because you will get better and you will also get faster at taking them.
- The most important thing is to look back at your photos and cases and learn from them.
- Good sources for purchasing materials and equipment: Amazon, Photomed, UKdentistry, Optident.
Source: enlightenesmiles.com
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