Digital photography and its use in the busy dental practice is ever increasing. Correct choice of equipment will save many hours of staff time and expense and is essential if consistent images are to be achieved. Modern digital cameras and associated macro lenses and ringflash, can last 5–10 years if handled carefully, and therefore is a good investment as an additional facility within the practice. There are many uses of photography in dentistry, from documentation to quality before and after images of dental treatments.
Clinical Relevance: This article will keep practitioners updated on the photographic equipment and uses within dentistry, and help to make informed decisions regarding photography in their practices.
Article
“While working at a camera shop in New York City in 1952, Lester Dine was approached by a dentist with a question. ‘How do I get my camera to light inside my patient's mouth?’ The flash the dentist was holding on top of his camera couldn't pinpoint light inside the mouth of his subject and every other method the dentist experimented with also proved fruitless. From that conversation and with a little tinkering and a lot of ingenuity, Lester Dine created the ring flash, a circular flash attached to the end of a camera's lens. By combining the ring flash with a lens capable of accurately capturing a close-up/macro subject, the first camera system designed specifically for intra-oral photography was born. From this creation, the world of dental photography grew and in a short time revolutionized the way dentists communicate with patients. The creation of the ring flash put the patient in the dentist's shoes and allowed them to see what the dentist could see in the most relatable form possible, an actual picture of the inside of their mouth.
Over time, the changes made to simplify the use of Ring Flash Cameras evolved, most notably with a feature called Through the Lens (TTL) flash metering. The ‘TTL’ concept allowed the camera to gauge the light around the subject through its lens and output light accordingly. Dentists no longer had to adjust flash levels using a power box in an attempt to take consistent photographs or take a series of photos bracketing different flash output. The now evolved camera could do the majority of the work, putting out more or less light depending upon the level of ambient light already around the subject. The ‘point and shoot’ nature of TTL flash metering made dental photography far less subjective and opened the role of ‘photographer’ to virtually any dental practice staff member, as the camera could basically take the same photograph regardless of user.
From its humble beginnings at the hands of an inquisitive dentist and resourceful inventor, the ring flash has become an essential tool for every dental practice, literally illuminating the world of dentistry.”
(Matthew Glassgold, www.dinecorp.com)
Ring flash was a major breakthrough in dental photography. Move on 40 or so years and we have another significant milestone in the integration and ease of use of dental photography in practice, digital cameras.
Digital cameras allow users to review their images on the back of the camera and send images to computers, tablets and smart phones wirelessly, giving patients an almost instant high resolution and undistorted view of the inside of their mouth.
1952: Dine introduces ring flash for dental photography (Figure 1);
1999: Nikon releases 2 megapixel cameras;
2000: The author was introduced to his first digital camera, the Coolpix 950 (Figure 2), at that time ideal for dental photography, and was converted to digital imaging at first demonstration.
2003: Canon produce first sub £1000 DSLR (Digital Single Lens Reflex), the EOS 300D.
Figure 1. Early Dine flash.Figure 2. Nikon Coolpix camera.
Photography in dental practice
Dental photography now has its place in many areas of dental practice and is an essential element of many MSc courses and associations such as AACD/ BACS. High quality ‘before and after’ images of your work are the best way to illustrate your skills and expertise. For many dentists/ nurses/hygienists/therapists, it will be a steep learning curve and, with practices becoming increasingly busy, there is little time for trial and error.
On the financial side, the investment can seem relatively high, but is often a lot less than many other ‘improvements/enhancements’ to your services. In terms of marketing and the benefits to your practice, it is a small investment with the potential to generate treatments. Poor equipment choice can be costly in terms of time and money! Investment in the correct equipment from the outset will save both time and expense and modern set-ups should have a lifespan of 5–10 years, if looked after correctly (Figure 3).
Figure 3. Canon set up with Dine flash.
For photography to be a practical option in the practice, it has to be quick and easy to use: 35 mm invariably took 5–10 minutes to take clinical images, often having to take several images to make sure you had the shot required. Digital photography will take less time, with the ability to review and check the image instantly. If photography is taking up valuable appointment time, the busy professional will think twice before using it, and miss many images of his/her best work!
Introducing clinical photography into your practice should be a whole team experience. Many practices are now routinely taking facial, profile, smile and intra-oral photographs of their patients, on their first appointment, and often on each subsequent appointment (Figure 4). This has two distinct advantages: first you have a record of the patient, which is a great ‘aide memoire’ for you and your patient; secondly, you have a record of the patient's facial/dental condition to refer back to, and the ability to monitor any changes (Figure 5).
Figure 4. Good consistent images are essential.Figure 5. Before and after images must be comparable in magnification, colour and exposure.
Your images need to be consistent, particularly in terms of focus, colour and magnification. Your camera needs to be set up to ‘point and shoot’ on standardized settings. This is the only way consistent images will be achieved, regardless of the image you are recording. We need our cameras set up to:
“Get the images we want, not what the camera wants to give us”.
Litigation is always going to be with us, so we need to safeguard ourselves against this.
As mentioned earlier, some practices are taking a set of photographs for new and existing patients. This is a great record to have ‘in the bag’. However, for these images to have the maximum validity they need to be a certain file type called ‘RAW’ or uncompressed. This option is on most DSLR cameras and can be taken at the same time as your JPEG (standard image file format). A RAW file cannot be manipulated as a JPEG can. A RAW file is an original unprocessed file, whereas a JPG is a file processed in the camera before saving to a memory card.
Digital photography is also ideal for producing images of your practice, and your staff for the website and perhaps a staff board in your practice. These photographs should be relaxed images, without the use of flash, which tends to make the image harsh and unattractive (Figure 6).
Figure 6. ‘Kind’ lighting makes an image more attractive.
Equipment
The DSLR and ring flash are still unsurpassed in the delivery of patient intra-oral images, and all the ‘young pretenders’, such as LED lights and CCS (Compact Camera Systems) are still no match.
The author has been delivering courses on digital dental photography for the past 13 years and has seen a huge change in the equipment course participants are bringing with them. Eight to ten years ago the compact camera was the main camera brought to courses however, over the last few years, there has been a complete conversion to DSLR, macro lens and ring flash photography.
Canon and Nikon are still, and are likely to remain, the manufacturers at the top of the field. Buying into these systems guarantees that there is plenty of support, technical and practical, on courses or on the web. Third party manufacturers produce accessories for these manufacturers and software developers are forever improving the functionality of these systems.
Size and weight of a typical clinical camera set-up has always been the slight barrier to investing in a system however, with correct technique, this should not be a problem.
Latest options
Canon has just launched one of two new models, the 100D (Figure 7), which is advertised as the world's smallest and lightest DSLR, something to consider, and the 700D.
One of the main competitors to the DSLR is the CSC (Compact System Camera), great for personal use. This can be used for clinical work with additional macro lens and flash, however, it is a ‘mirrorless’ system and so, in the author's opinion, isn't ideal. Precise focus and magnification can also be an issue and the costs of putting a system together is sometimes more than for a DSLR system.
Figure 7. Canon DSLR.
Lens options
The best choice for dental photography is still a ‘prime’ ‘macro’ lens.
This lens needs to give you quality close-up images down to 1:1, while still maintaining a good working distance, ie 10–12 inches from the subject (patient). This will only be achievable with the use of a 100 mm or 105 mm lens; 50 mm or 60 mm lenses will restrict your ability to get close-up views at the back of the mouth (Figure 8). Image stabilization (IS) is not necessary for dental photography; a non IS lens will be much cheaper than its IS equivalent. A good quality UV filter is a good idea for your lens, as most lenses with ring flashes attached won't allow the lens cap to be fitted.
Let's start with the best advice I can give…DO NOT BUY AN LED RINGLITE, even if it says LED flash. They are a fraction of the power of ring flash and all your camera settings will be compromised, losing you quality and depth of focus. Ring flashes come in many types, all of which work (Figure 9). However, you do need a ringflash that will work on ‘manual’ settings to get consistent images, and generally you get what you pay for. The cheaper options are generally underpowered and not as robust, some use plastic components and are likely to fail.
Figure 9. Typical dental photography set-up.
The future
The future of dental photography in the dental practice is all about patient communication, and the use of wifi image transfer to ‘tablets’ such as the iPad and Android systems. The technology is here now, but still needs to be more consistent, to feature in all surgeries.
As mentioned earlier, with litigation cases increasing, the need to have quality images and storage is essential. RAW images should always be taken, certainly for all of your new patients on their first visit, as a legally robust format. This brings its own challenges in terms of storage and back-up.
