Implementing Photography in Medical Services
By Matthew Glassgold
Virtually anyone who has visited a dentist in the last 30 years has seen pictures of the inside of their mouth. Cameras ranging in type from film, to video to today’s digital photographic systems are a staple in virtually every dental practice regardless of specialty. But 70 years ago that wasn’t the case, there was x-ray, but nothing that a patient could relate to and say “That’s my mouth, I see what the problem is and how it effects me.”
By Matthew Glassgold
Virtually anyone who has visited a dentist in the last 20 years has seen pictures of the inside of their mouth. Cameras ranging in type from film, to video to today’s digital photographic systems are a staple in virtually every dental practice regardless of specialty. But 60 years ago that wasn’t the case, there was x-ray, but nothing that a patient could relate to and say “That’s my mouth, I see what the problem is and how it effects me.”
Over a half century ago, dentists began searching for a photographic device that could put patients in the dentist’s shoes to see what they see. However, even with the popularity of conventional film photography growing, there was still one huge road block to taking dental pictures. There was no clear way to get light from the camera’s flash inside the dark cavern that is the mouth. While the technology of close-up lenses had grown to the point where a camera was capable of photographing a close-up picture of an intra-oral subject, getting light into the mouth to take the picture was another story. Traditionally cameras produced light from a source on the camera body and this light projected out at a distance to illuminate the subject. But with close-up photography, often the lens was inches from the subject. This light projecting from the camera body could not disperse fast enough to pass enough light deep inside the mouth. Therefore, the concept of dental photography was limited to basically facial photography.
This changed with Lester Dine’s invention of the Ring Flash in 1952. The Ring Flash, a circular flash that attached to the end of the camera’s lens, had the ability to pinpoint light directly into the patient’s mouth, providing full illumination from external anteriors to posterior intra-oral quadrant pictures. This invention revolutionized the concept of dentist/patient communication. Now through photography, a patient could see what a dentist could see and understand the importance of treatment. In addition photographs of existing patients could be used to show patients potential before and after scenarios as well as “worst case scenarios” should patient decide against treatment. This invention meant photography could now be used as a teaching tool, forever changing the way dentists were taught in school and via continuing education. Developments in the field could be documented photographically and included in slide presentations from lectures creating the most visual teaching tool possible. The complete dental record was forever changed.
Today’s ring flash physically differs very little from the original Ring design, to improve portrait photography, an additional flash called a “Point Light” was added to the Ring Flash system, allowing the user to choose between two distinct flashes depending upon the photographic subject, ring for intra-orals, point for facials. In addition a concept called TTL (through the lens) flash metering was created. This concept allowed the camera to judge the light around the subject through the lens, and to control the light output based on this reading. This took the guesswork out of photography. It made the process of taking a dental picture basically three steps, look through the camera, focus, and take the picture. TTL flash metering makes the flash output as consistent as possible.
As the popularity of dental photography grew through the 1960’s and into the 1970’s a limitation of 35mm film based photography became clear. The doctor could take photographs while the patient was at their office, but they couldn’t review those photographs with them until the film was developed. And with elements of human and mechanical error, as well as inefficient film processing effecting the output of even the finest dental photographer’s work, there was no way to even insure that the developed photos would accurately represent the case. There was a clear need for immediate and accurate photographic results. This need coincided with the invention of instant film cameras. While not the quality of 35mm film, instant cameras offered the user the ability to take a photograph and see results within a couple of minutes. The cameras could actually take a picture and process it to special film inside the camera. Lester Dine modified the first instant camera and affixed lenses and a flash modification to the camera creating the dental world’s first instant photographic system. This device was followed by other instant output cameras and created an entirely new way for doctor’s to educate patients.
In the 1980’s computers started to take a bigger role in the dental office, so did the desire of dentists to computerize photography. The first foray into computerized picture taking was with intra-oral video cameras. The video cameras were revolutionary in many ways. The intra-oral video cameras were built into wands small enough to fit into the patient’s mouth. With video not only could the patient see a photo of their case, but they could actually see inside their mouth live, in real time. The dentist could point the small video camera at a particular tooth or segment of the mouth and discuss treatment plans. Plus, as computers became more capable, the images could actually be imported into cosmetic imaging programs and edited to show potential before and afters. With the art of cosmetic dentistry growing and elective cosmetic procedures on the rise, this form of imaging was instrumental in selling cases. Not only could doctor’s use photography to show patients before and after’s of other patients, but via computer imaging, they can actually show a patient how potential changes could effect the way they look. This concept has become so popular and widely marketed that today many prospective patients not only enjoy seeing the potential before and after picture, but will shop for doctors that offer this technology.
While intra-oral video technology was certainly influential to the field of photography, it was limited in several ways. First and foremost, like instant print pictures, it lagged far behind 35mm film cameras in quality. Second, video’s integration with computers was cumbersome, often requiring an elaborate video capturing system. Third, the video systems were not portable and generally required a dedicated video image space. They were also expensive.
Ultimately, the popularity of intra-oral video cameras leveled off and were replaced by what many consider the most important invention in dental photography since the ring flash, Digital Photography. Digital picture taking combines the best of all three of the previous photographic concepts, the quality of 35mm film, the speed of instant photography, and the computerized integration of video. Digital cameras integrate easily with computers by plugging directly into a computer USB port. And work seamlessly with virtually all Windows and MAC imaging programs. When plugged into computers most digital cameras are assigned drive letters and accessed in the same manner items on the hard drive are accessed. Like film and instant cameras, not all digital cameras will work intra-orally, but with the right digital camera in hand, dentists possess an incredible tool.
The old saying that a picture is worth a thousand words can be taken a step further when it comes to dental photography, where a single photograph can offer a virtually endless number of vital uses for a busy practice. While type of practice and specialty will effect how images are used in general, virtually all practices will certainly find endless uses for photographs.
First and foremost photographs compliment patient records. Photographs along with written description paint a complete picture of a case. They serve as an ideal and descriptive way to document the progress of a case from every angle and during every office visit. Charting case progress, monitor everything from healing after surgery to cancerous growths to cracks in fillings, and most importantly, have a visual reference to all cases available in your patient charts. The concept of digital photography enhances the ultimate goal of many practices to move toward a paperless office. Digital images can be added directly to practice management programs to make for the ultimate patient record.
The use of digital images is endless, the following are a few of the most common applications…
Communication with Insurance Companies- With insurance companies controlling how much and when to pay and putting the burden of proof on procedures firmly in the laps of the dentists, photographs present a clear description of procedures. A series of case pictures along with a written description is the most thorough way to gain insurance company compliance. With more and more insurance companies moving to electronic communication, users of digital cameras, can simply e-mail image and text in minutes. The use of computer software to include images in letters, before and after layouts or case descriptions, makes for a fast and effective way for a doctor to present cases to insurance companies.
Dental Laboratories- where a small discrepancy can make a big difference, communicating the right shade, and description of a case to a dental lab is essential. A clear photograph of the subject along with shade tab information and case description is the most complete way to show off cases to labs. Once again dental imaging software can be used both to present a case to the lab and to show patient’s potential results via computer imaging.
Malpractice Suits-it’s always said that truth is the best defense. With photography, dentists have a clear and visual explanation of a case, with before and afters, progress reports, and treatment response, in the unlikely event a malpractice suit has to be fought, photography will go a long way toward presenting the dentist’s side of the issue. The entire treatment process from first visit to final result can be easily charted via picture taking.
Selling Cases- One of the most interesting developments in dentistry has been the growing popularity of cosmetic dentistry and elective procedures. There’s no way to deny it, photography helps sell cases. Whether it’s showing patients their own pictures, before and after’s of previous cases, or using cosmetic imaging software to simulate before and afters the pictures you take makes the case seem “real” to the patient. By combining a patient’s pictures with before and afters of similar cases or using the latest cosmetic imaging software to simulate potential before and afters, any patient considering a cosmetic procedure will have a very clear understanding of the benefits of treatment, the same day they visit the doctor’s office.
Digital Photography is by far the most popular format of camera sold today. The once popular 35mm and instant cameras have become a thing of the past. With the ability to match the quality of film combined with the immediate access of instant photography, digital picture taking truly offers the best of both worlds. Digital images are produced in a computer file format both MAC and Windows systems can readily understand, and their interaction with computers is as simple as a straight plug in to a USB port on a computer. Digital Images can be transferred anywhere over the internet. They can be printed on virtually any computer printer and they can be stored on external storage devices for long term access. A simple attachment from computer to digital projector allows for immediate presentation for lecture, totally eliminating the need for 35mm slides. In addition graphics can be combined with digital slides to create an incredibly dynamic presentation.
Digital Cameras also offer the ability to by-pass a computer completely. So for the computer phobic user, the cameras can actually communicate directly with photo printers to produce hard copy prints. Mimicking the output of instant cameras, with one exception, if a user doesn’t like a photo they’ve taken, they can always re-take it prior to hard copy print.
While the technology is new, the dilemma of finding a camera to photograph intra-orally has not gotten any easier. There are hundreds of digital cameras on the market for the general consumer, but less than a handful will provide the range of intra-oral photography required by dentists.
The limitation of over the counter digital cameras is in lens and lighting. Most over the counter digital cameras don’t have the close up capability that dentists need, then those that do often don’t provide enough depth of field to see the entire close-up picture in focus.
An even bigger hurdle to overcome is lighting. As was the case with 35mm and instant cameras, intra-oral lighting is a major problem. The small format over the counter digital cameras have built in flashes that normally aren’t capable of pinpointing light into the patients mouth, nor can they meter the light output . The other option is Single Lens Reflex digital cameras. These cameras offer the ability to add additional lens and flashes much like 35mm cameras, to achieve the ideal dental photographs. To the surprise and disappointment of many 35mm camera users pre-existing manual focus macro lenses and ring flashes generally do not transfer over to today’s digital SLR’s.
Fortunately, there are digital camera solutions for dentists, and they come in the form of both the small format digital cameras and the digital SLR systems.
There are two very clear directions to go with photography, for those looking for fast, simple, intra-oral picture taking, the concept of small format digital cameras is very attractive. Small format digitals generally weigh a pound or less and often can be held with a single hand. These cameras are attractive to a dentist looking for fast and easy photography. Knowledge of cameras and photography in general is less important with these systems. Generally, the user follows a live video screen on the back of the camera, uses a telephoto zoom on the camera to gain macro close-up, then autofocuses and takes the picture. Results are immediately displayed on the back of the camera. With the small format camera like the Dine Digital Solution, a camera that weighs less than a pound is modified to work as an intra-oral camera. The camera is used from usually between 8 and 12 inches from the subject (the average SLR camera is used 4-6 inches from the subject). This distance from the subject allows the light from the camera time to disperse to fully illuminate the intra-oral subject to the back of the mouth. The camera itself has been modified so it can meter the flash and put out the right amount of light. For instance a posterior quadrant photograph would require more light than an anterior smile, the camera is capable of gauging appropriate light output and adjusting accordingly.
The Single Lens Reflex cameras offer the highest level of intra-oral picture taking. For those publishing, lecturing, applying for academy accreditation this camera system will best reflect ones dental work. The SLR film cameras look and feel like the 35mm cameras of the past. They utilize either 105mm or 60mm macro lenses as well as Ring and Point Flashes. The digital SLR’s are capable of TTL’ing the flash output for maximum consistency. The camera’s lenses can be used in manual focus allowing users to standardize their photography with the ultimate goal of consistent before and after photography.
The Single Lens Reflex cameras are larger and heavier than their small format digital counterparts. They can be more intimidating to a user unfamiliar with cameras, however, the style and concept of SLR photography has proved itself to me tried and true over the last 50 years and with a period of practice, anyone in the office can use these cameras.
For any practice that has never taken photographs before, implementing a photographic plan can take a bit of work and staff member acceptance. First, auxillaries have to understand and appreciate the importance of dental photography. In addition understanding how to use their camera and seeing the positive reaction patients have to pictures is essential. Having time to use and practice with the camera is essential. One nice advantage of digital photography is memory cards can be used to for practiced, erased, and used again, so there’s no costs involved with practicing with digital cameras.
The basic dental photographer’s goal is to accomplish a simple series of intra-oral and extra-oral photos, an anterior, lateral, occlusal using a mirror, facial, profile, and intra-oral quadrant. It’s reasonable to expect one new to taking pictures to be able to take this series of photos within a day or two of purchasing a dental camera system. The newest cameras go a long way to simplifying picture taking by controlling flash output internally. This concept called “Through the Lens” (TTL) Flash Metering revolutionized photography by taking the guess work out of picture taking, allowing the camera to gauge light in the room or in the case of dental photography the light inside the mouth, and adjust accordingly. In addition some single lens reflex cameras are equipped with standardization guides on their lenses to show users exactly where the lens should be set for the different popular dental pictures.
Beyond learning how to use the camera, competency with two essential tools for dental photography are important. The intra-oral mirror, and cheek retractors work hand in hand with the camera. The cheek retractors are designed to pull the cheeks away from their natural position so that they do not block the teeth and gums. The retractors allow full access for the flash to reach the posterior of the mouth. The intra-oral mirror works to allow the camera to photograph subjects that would be difficult or impossible to access by photography directly into the subject. An upper or lower arch photograph for instance, is take by placing a mirror on the opposite side of the arch. The mirror can then be angled to reflect the full arch above or below it. The photographer would then focus and take pictures off of the reflected surface.
It is Lester A. Dine Inc.’s ultimate goal to make the transition into Dental Photography as simple as possible for any dental practice. Provided with all Dine cameras is dental specific instructions for use, and lifetime telephone support. Regardless of the camera you choose we will provide you with the help you need to make it a vital part of your practice. Please e-mail us with any questions at lesterdineinc@gmail, catch us in Live chat on dinecorp.com or call (800) 624-9103.