OBSERVATIONS GORDON J. CHRISTENSEN, D.D.S., M.S.D., Ph.D. Important clinical uses for digital photography 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, practitioners. CHOOSING THE PHOTOGRAPHER 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. OBSERVATIONS 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. OBSERVATIONS 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. SUMMARY 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 CLINICAL RESEARCH 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.