Important clinical uses for digital photography

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					                     OBSERVATIONS GORDON J. CHRISTENSEN, D.D.S., M.S.D., Ph.D.

Important clinical uses for digital
      remember well the dental       raphy can assist dental                     be significant in not only a clin-

I     clinical photography of the
      past, when making a clin-
      ical photograph required
      significant expertise and
effort, and the results were
unknown for days to weeks after
making the image. Fortunately,
                                     CHOOSING THE

                                     The number of staff members in
                                     dental offices differs enor-
                                     mously. Some dentists work
                                                                                 ical sense but also a legal sense.
                                                                                 The number of dental practi-
                                                                                 tioners involved with legal
                                                                                 activity each year is astounding,
                                                                                 and it does not appear to be
                                                                                 decreasing. A malpractice
                                                                                 attorney in Salt Lake City
those days are past. Digital         with one or a few staff members,            observed to me last year that
technology has revolutionized        while others have many                      many dentists in the United
clinical dental photography.         employees. Unless the dentist               States were involved in lawsuits
Today’s pictures, instead of         likes to be in charge of the pho-           concerning oral therapy (David
requiring days’ or weeks’ time to    tography for the practice, I sug-           Epperson, Esq., oral communi-
be developed, are available in       gest that the responsibility of             cation, Nov. 1, 2004).
seconds and can be displayed on      making the photographs be dele-                Digital cameras are easy to
computer screens or large pro-       gated to a competent staff                  use, in terms of both making
jection screens within minutes.      person.1 The dentist and the                and storing the photographic
Images can be rotated, enhanced,     staff member should decide                  images. There is no reason to
lightened, darkened, cropped or      what images they want to make,              avoid recording potentially
altered in almost any way a pho-     and these images should be                  legally threatening clinical situ-
tographer would wish. For a typ-     standardized in size and expo-              ations and storing them in dig-
ical dental practitioner with min-   sure. The staff person in charge            ital form for documentation
imal photographic expertise, the     should have responsibility for              needs. Having served as a wit-
new digital photographic tech-       making the image, storing it in             ness in numerous dental trials,
nology is one of the most signifi-   the computer and backing the                I can affirm that when photo-
cant potential improvements          images up frequently.                       graphic documentation of the
available for a dental practice.                                                 specific clinical situation under
                                     DOCUMENTING TREATMENT
   After many years of involve-                                                  question is available, the den-
ment with conventional dental        Digital photography has greatly             tist’s case is much easier to
photography, I will share my         increased the ease of docu-                 defend.
views on how digital photog-         menting treatment, which can                   Busy dentists accomplish

                                                                                          JADA, Vol. 136, January 2005   77
                              Copyright ©2005 American Dental Association. All rights reserved.

  hundreds of procedures per                  by television “makeover” pro-                a patient has a missing maxil-
  week. Which procedures should               grams. These often are the                   lary lateral incisor. You can
  be documented? Each practi-                 patients who decide that some-               labor through the various treat-
  tioner has to make his or her               thing is wrong after treatment               ments verbally, with minimal
  own decision. In my opinion,                and seek legal counsel.                      patient understanding, or you
  potentially legally threatening                Case-documentation photo-                 can turn on your computer and
  situations should be docu-                  graphs should be dated and filed             show the patient the alternative
  mented. Examples are implant                in a manner that makes them                  treatments. As an example,
  surgery or placement of several             retrievable easily. In comparison            there are several treatment
  esthetically pleasing, but rela-            with word-processed documents,               alternatives for one missing
  tively weak, all-ceramic crowns.            photographic images consume                  maxillary lateral incisor,
  At least the starting and ending            significant space in a computer.             including
  conditions in such procedures               Some practitioners have practice             da cantilever fixed partial den-
  should be documented, as well               management computer systems                  ture abutting the canine;
  as any peculiar occurrences                 that facilitate image storage in             da three-unit fixed partial den-
  during treatment. This docu-                each patient’s standard dental               ture extending from the canine
  mentation requires only min-                file. Others who do not have                 to the central incisor;
  utes and can be assigned to a               such systems can file photos in a            da removable partial denture
  competent staff member.                     simple alphabetical computer                 with a metal substructure;
     I suggest making documenta-              file. Small, easily used computer            dan all-polymer removable par-
  tion images of any treatment                information storage systems can              tial denture;
  that is planned as an esthetic              be purchased to augment                      dan implant-supported crown;
  upgrade. If the patient complains           storage in office computer sys-              dan acid-etched, resin
  that the treatment result is not            tems, allowing storage of enor-              cement–retained, ceramic, resin-
  as expected, the preoperative and           mous numbers of images in a                  based composite or porcelain-
  postoperative images can be                 space about the size of a deck of            fused-to-metal fixed partial
  useful in demonstrating to the              cards. I have used such small                denture;
  patient the positive change,                information storage systems to               dnothing.
  thereby dispelling allegations              back up photos in the event of                  Significant time is required to
  that improvements were not                  an office fire, flood, earthquake,           secure informed consent from
  made. These images certainly                burglary or other problem. The               the patient for all of these treat-
  are valuable if legal activity is           small back-up file should not be             ment options.2,3 With adequate
  initiated by the patient.                   kept in the same environment                 preparation, a practitioner
     Any comprehensive or expen-              as the main storage area, and it             easily can show treatment alter-
  sive dentistry should be docu-              should be backed up frequently.              natives based on previous treat-
  mented. This includes several                  Another significant reason for            ment accomplished with other
  crowns, complex fixed or                    making documentary treatment                 patients. When the patient sees
  implant prostheses, or major                images is to verify the treatment            the various alternatives and
  periodontal or maxillofacial                rendered to third-party payment              receives adequate oral or
  surgery.                                    companies. I know of several                 written information to satisfy
     Photographs should be made               recent situations in which                   informed consent requirements,
  of patients who appear to be                sending a dental benefit com-                the decision about which treat-
  suspicious or overly anxious                pany a digital image of the                  ment to select is faster and
  about the treatment they have               treatment carried out has pre-               easier.
  agreed to receive, or who have              vented a confrontation about the                Another example I use rou-
  had previous legal activity with            treatment. Such images easily                tinely is education regarding
  a dentist. Unfortunately, this is           can be sent by e-mail in seconds.            treatment for the edentulous
  a growing group of patients,                                                             mandible.4 Patients with this
                                              PATIENT EDUCATION
  probably because of the vast                                                             condition can be treated with a
  amount of dental information                The following example shows                  typical mandibular denture,
  available on the Internet and in            the desirability of having a                 with two implants and an over-
  lay publications, and because of            library of clinical images for               denture, or with several
  the high expectations promoted              patient education. Let’s assume              implants supporting a fixed or

  78   JADA, Vol. 136, January 2005
                               Copyright ©2005 American Dental Association. All rights reserved.

removable implant prosthesis.        fast. However, time must be                  higher resolution is the com-
Patients who see the images of       scheduled to categorize them                 puter space necessary to store
the alternatives are able to         and place them in a computer.                the images. The higher the
understand the concepts rapidly      In my opinion, the time thus                 image’s resolution, the more
and easily, and their acceptance     expended is well offset by the               computer storage space it
of treatment is facilitated. Prac-   many advantages that arise                   requires.
titioners quickly can build a        from this activity.
library of slides covering the
                                     DIGITAL CAMERAS
procedures they accomplish                                                        Digital photography almost has
most commonly.                       It has been my observation from              overtaken the conventional pho-
   I suggest making a list of the    teaching continuing education                tographic film industry. Most
most-used procedures in your         courses that most dentists in                professional photographers are
practice, developing a library of    attendance own digital cameras               using either digital photography
images of those procedures as        but do not use them for clinical             alone or a combination of digital
rapidly as possible, and filing      purposes. Some dentists still                and conventional film photog-
the images in a computer for         need to purchase a digital                   raphy. The trend toward digital
patient-education purposes.5         camera, and it is slightly dis-              photography is not likely to
Create a library of educational      couraging that most digital cam-             change. Using digital photog-
images that can be filed by sub-     eras on the market now will be               raphy in the dental office is fast,
ject matter, unlike the cus-         adequate for only a few years,               easy and highly useful for docu-
tomary method of filing images       because of the rapid develop-                menting treatment, carrying out
of specific patients in the indi-    ment in this area. Nevertheless,             patient education and accom-
vidual patient files.                I strongly advise dentists to pur-           plishing clinical research.
                                     chase clinical digital cameras               Supervision and use of this new
                                     and learn how to use them as                 technology can be delegated to
A sadly neglected area of poten-     soon as possible. There are                  staff members, and it will pro-
tial practitioner-generated          many digital cameras on the                  vide many benefits to dentists
research knowledge is computer       market that can be adapted to                and patients. s
storage of images of treatment       dental use.6                                   Dr. Christensen is co-founder and senior
accomplished, the date of treat-        The cost of an adequate                   consultant of Clinical Research Associates,
                                                                                  3707 N. Canyon Road, Suite No. 3D, Provo,
ment and any peculiar informa-       dental digital camera ranges                 Utah 84604. He has a master’s degree in
tion that may relate to the func-    from $1,300 to $2,000. Some                  restorative dentistry and a doctorate in educa-
                                                                                  tion and psychology. He is board-certified in
tional longevity or the long-term    examples of easy-to-use dental               prosthodontics. Address reprint requests to
esthetic acceptability of the        digital cameras are the Canon                Dr. Christensen.
treatment. It is easy to visualize   PowerShot A95 (Canon U.S.A.,                   The views expressed are those of the author
the potential research informa-      Lake Success, N.Y.), which is                and do not necessarily reflect the opinions or
                                                                                  official policies of the American Dental
tion that could be generated if      packaged for dental use in a kit             Association.
many dentists collected thou-        called DentalFoto 95 by Dental
                                                                                    Educational information on topics discussed
sands of digital images of a         Learning Centers (Issaquah,                  by Dr. Christensen in this article is available
restorative procedure, a peri-       Wash.), and the Kodak DX6490                 through Practical Clinical Courses and can be
                                                                                  obtained by calling 1-800-223-6569.
odontal treatment or an              Dental Digital Camera System
orthodontic procedure, and those     (Eastman Kodak, Rochester,                     1. Christensen GJ. Why expand the role of
                                                                                  dental staff members? JADA 2001;132:529-31.
images then were evaluated in a      N.Y.).                                         2. Christensen GJ. Informing patients about
controlled manner by a clinical         Most digital photography                  treatment alternatives. JADA 1999;130:730-2.
                                                                                    3. Christensen GJ. Elective vs. mandatory
researcher. Such a possibility is    authorities agree that making                dentistry. JADA 2000;131:1496-8.
not likely to happen soon, but       dental images at a level of about              4. Christensen GJ. Treatment of the edentu-
                                                                                  lous mandible. JADA 2001;132:231-3.
each practitioner can collect        3 million megapixels probably is               5. Christensen GJ. Educating patients about
images from his or her own           adequate, and I agree with that.             dental procedures. JADA 1995;126: 371-2.
                                                                                    6. Clinical Research Associates. Point &
practice to guide in selection of    However, you may increase the                shoot digital dental cameras. CRA Newsletter
materials, devices and tech-         detail in the images by setting              2004;28(9):1-2.
niques for personal use. Collec-     some of the cameras at a higher
tion of the images is easy and       resolution. The challenge of

                                                                                          JADA, Vol. 136, January 2005        79
                              Copyright ©2005 American Dental Association. All rights reserved.

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