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Guide in Dental Photography

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Guide to Dental
Photography
THIS OVERVIEW WILL HELP PROVIDERS UNDERSTAND THE
FUNDAMENTALS OF DENTAL PHOTOGRAPHY, ALLOWING THEM
TO PREDICTABLY DOCUMENT CLINICAL PATIENT IMAGES
By Fernando J. Haddock, DDS; Barry D. Hammond, DMD;

P
and Mario F. Romero, DDS
hotographs are vital in communicating with patients the outward view of their smile.
Imperfections that are not readily visible to the patient will be apparent in still
photographs. Thus, dental photography allows the patient to visualize his or her smile
and oral condition with the same acute perspective as the dentist, which helps the patient
understand the rationale for recommended treatment.1

Whether the use of dental photography is solely for docu- wand cameras.3 Clinicians can
mentation or other purposes (social media or marketing, for choose from multiple systems
example), before taking any images it is essential to obtain writ- for dental photography that will
ten consent for photography, and take steps to protect patient work well for most practices.
confidentiality.2 Photographic consent can easily be added as However, the digital single lens
part of the patient information documents that are completed reflex (DSLR) camera is the most ideally
during the new patient examination process. suited for practices that wish to use photography for documentation for lectures
Selection of the most suitable equipment for extraoral or publications;4 DSLR technology is considered to be the system of choice for
and intraoral photography requires knowledge of digital predictable dental photography.5 A DSLR camera system equipped with a macro
photography and can be confusing for dental practitioners lens (85–105 mm) and an external ring flash mounted in front of the lens is
due to the wide varieties of models available, including required for high-quality intraoral macrophotography (Figure 1).6

1 Decisions IN DENTISTRY • December 2018 DecisionsInDentistry.com

 (which would otherwise be
distracting). Cheek retractors
are available in clear plastic or
metal, and are either single- or
double-ended (Figure 2). Dou-
ble-ended retractors provide
both a small and large curva-
ture. This shape allows adapt-
FIGURE 1. Digital single lens reflex dental FIGURE 2. Cheek retractors FIGURE 3. Occlusal and buccal mirrors. ability to a variety of mouth
photography camera setups. (plastic and metal). sizes.6 Selection is a matter of
preference; however, plastic
Compared to a point-and-shoot camera system, the advantages of a retractors are less noticeable in the image should it prove impossible to elim-
DSLR setup include excellent image quality, speed of operation, increased inate it fully while framing the photograph.
depth of field, and adaptability. While the DSLR systems were traditionally Intraoral mirrors are invaluable when taking occlusal- and buccal-
thought to be more complicated to learn, bulkier and more expensive, view images because the photographic angle does not typically allow for
today’s systems are smaller and lighter, and are similar to other systems in capturing these photos from a direct view. Intraoral mirrors are available
terms of cost. The higher-end cameras can be more expensive, but such in several sizes, and a standard set should include buccal and occlusal
systems are not needed in the typical dental practice, as excellent results mirrors (Figure 3). They are used to provide a reflected image when areas
are available with less costly systems. Additionally, most photographs can of difficult access are being photographed.3 To prevent mirror fog, it is
be taken with a minimum of settings to simplify the process while still useful to warm the mirror in a water bath, or simply ask an assistant to
yielding quality results. gently blow air across the mirror with the triple-way syringe.7 Mirrors are
also available with handles, thus simplifying occlusal and buccal imaging.
CAMERA SETTINGS AND ACCESSORIES Their use minimizes the possibility of fingers being shown in the images
All DSLR cameras require a very specific setup for clinical dental photography.3 (which is more likely with traditional mirror systems). To protect the reflec-
Proper exposure setup and flash calibration can be obtained through dental tive surfaces from potential damage, it is strongly advised to wrap mirrors
photography courses, or by purchasing a camera from companies that special- separately for autoclaving purposes, and not mix them together with
ize in systems adjusted for optimal dental use (PhotoMed, Dine Corporation other instruments.
and Norman Camera are three examples). For an inexperienced operator, these
settings can be overwhelming. The authors recommend setting the camera BASIC IMAGES
and lens in manual mode, as it gives full control of the following exposure fea- Each patient or clinical circumstance may dictate the need for specific
tures: aperture or f/stop, shutter speed, ISO and magnification (Table 1). Using intraoral or extraoral images. In general, practitioners should capture seven
these recommended settings simplifies the process greatly and will work for basic views to record a patient’s clinical condition during the initial visit.
most clinical scenarios. The authors recommend using a team of three (including the patient) to
Cheek retractors greatly contribute to the final outcome of intraoral pho- achieve an ideal outcome. The patient, photographer (dentist or other
tography. These essential accessories are used to retract the lips, labial and office personnel), and dental assistant should each have a role in the photo
buccal mucosa from the field of view. This allows the maximum amount of shoot. The authors recommend the patient hold the retractors for
light to enter the oral cavity, thereby improving visibility. Additionally, using improved comfort, as they can better control the amount of tension
retractors removes miscellaneous soft tissue structures from the field of view applied. The camera and mirrors are the responsibility of the photographer
in order to properly frame the image. Prior to taking the photograph, the
FERNANDO J. HADDOCK, DDS, is an assistant professor in dental assistant will dry all teeth involved, provide suction, and control
the Department of Restorative Dental Sciences at the University of mirror fog by gently blowing a light stream of air across the mirror (as
Florida College of Dentistry in Gainesville. Prior to joining academia, noted, mirrors can also be prewarmed). The proper technique and out-
Haddock, who is an author and diplomate of the American Association
comes are shown in Table 2. Additional views may be captured, as needed,
of Dental Consultants, was in private practice for 20 years.
based on the patient’s clinical findings or treatment provided, as well as
BARRY D. HAMMOND, DMD, is an associate professor in
the Department of General Dentistry at The Dental College of the practitioner’s preferences. Supplemental photographic tips and sug-
Georgia at Augusta University in Augusta, where he serves as the gestions are provided in Table 3.
director of dental continuing education. Prior to joining the university
in 2006, he practiced general and esthetic dentistry for 15 years. TABLE 1. Basic Camera Settings
MARIO F. ROMERO, DDS, is an assistant professor in the Extraoral Intraoral
Department of Restorative Sciences at The Dental College of
Aperture (f/stop) f/8–10 f/20–22 to f/32
Georgia at Augusta University. Romero maintained a private
practice for 15 years prior to joining the university in 2013. Shutter speed 1/125–200 1/125–200
He can be reached at [email protected]. ISO 100–200 100–200
The authors have no commercial conflicts of interest to disclose. Magnification 1:10 1:2 or 1:3

DecisionsInDentistry.com December 2018 • Decisions IN DENTISTRY 2

 key takeaways
TABLE 2. Basic Recommended Images
Image Cheek
Retractors Mirror Technique Image • Dental photography allows the patient to visualize his or
her smile and oral condition with the same acute
perspective as the dentist, which helps the patient
Full Face understand the rationale for recommended treatment.1
No No
(smiling)
• Before taking any images, clinicians should obtain
written consent for photography, and take steps to
protect patient confidentiality.2
• A digital single lens reflex (DSLR) camera is ideally suited
Smile No No for practices that wish to use photography for
documentation for lectures or publications.4
• Compared to a point-and-shoot camera, the advantages
of a DSLR setup include excellent image quality, speed of
operation, increased depth of field, and adaptability.
Anterior Yes No
• All DSLR cameras require a very specific setup for clinical
photography,3 as proper exposure setup and flash
calibration are essential.
• Cheek retractors are key accessories that help retract the
lips, labial and buccal mucosa from the field of view.
Right Buccal Yes Yes
• Intraoral mirrors are invaluable when taking occlusal-
and buccal-view images because the photographic angle
does not typically allow for capturing these photos from
a direct view.
Left Buccal Yes Yes • As a general rule, practitioners should take seven basic
views to record a patient’s clinical condition during the
initial visit.
• Original images should be stored in a folder and labeled
with the patient’s name and date, and marked as
Maxillary “original photos.”
Yes Yes
Occlusal

The mandibular occlusal view is one of the most challenging to obtain

Mandibular due to the tongue. In the majority of the cases, the tongue can be
Yes Yes
Occlusal retracted by placing the occlusal mirror underneath it, followed by posi-
tioning the edge of the mirror distal to the second molar (see Table 2). In
many cases, having the patient tip the chin slightly upward can also
Ideally, the patient should be photographed in a dental chair, which enhance visibility. As is the case for all mirror images, care should be taken
should be adjusted to enable the photographer, without having to reach or to only include the mirror image of the teeth in the photograph.
bend uncomfortably, to capture an adequate view. In some cases (depending While not illustrated in this article, the practitioner may wish to consider
on the space available), taking the full face and smile photos may be easier if additional photographic alternatives, such as rapid fire or video photography
the patient is either seated in an operator chair or standing at the same height in order to better visualize the lips in motion, which may differ considerably
as the photographer. when compared to a single still image. This approach can be invaluable in
For anterior, buccal and occlusal imaging, it is easier to obtain consistent
views if the patient’s head is kept level, with the Frankfort plane horizontal,8 TABLE 3. Tips for Quality Dental Photography
as seen in the images in Table 2. For the full-smile and anterior retracted • Always use cheek retractors
views, some operators prefer to shoot these images from a direct horizontal • Move camera close to patient to avoid unwanted structures in the image
approach rather than from a slightly tipped-down approach, as is illustrated • Use dental photography mirrors and add operatory light on the mirror, as this
provides more intraoral light, which helps when focusing
in this article, but it is a purely a matter of preference. For lateral views, it • Warm the mirror or blow air across it to prevent fogging
is important to have the patient use the narrow end of the metal cheek • Take as many images as you like; you can delete them later
retractor on the side being photographed, while using the wide end on • Set camera and lens to Manual mode to control the aperture and shutter speed
• Keep same angle of view and magnification ratio from right to left for
the contralateral side. This will provide room for the lateral mirror and keep consistency
the lips from the opposite side from collapsing into the field of view. The • For portrait shots, consider use of light diffusor and reflector, as well as a
nondistracting background
lateral mirror should be placed distal to the second molars and used to • For mirror images, flip when adding to a presentation or photo album as they
push the cheek away from the teeth, as seen in the images in Table 2. will be reversed

3 Decisions IN DENTISTRY • December 2018 DecisionsInDentistry.com

smile design planning for anterior prosthodontic procedures, as static photos While there is a learning curve to mastering high-quality dental photog-
are often an inadequate basis for smile design, and the perception of esthetics raphy, it is readily achievable with practice and consistent application in
in motion differs from the static view.4 clinical practice.

IMAGE FORMAT SUMMARY

Most camera systems are set up to store images in Joint Photographic Although the rapid pace of innovations in digital photography often con-
Experts Group (JPEG) format. The images are compressed, but this format founds dental professionals, high-quality, accurate clinical photographs can
is typically considered ideal for daily use, as it represents an acceptable easily be obtained by appropriately trained staff using the proper equipment,
blend between file size and image quality. However, some practitioners settings and technique. Understanding the basics of dental photography —
prefer to save the images in RAW format, as the data is uncompressed and including equipment and technique — and properly applying these funda-
the digital equivalent of a negative produced by a 35 mm film camera. mentals will help dental teams document consistent, and clinically useful,
Compared to JPEG files, RAW format offers the maximum storage of infor- dental photographic records. D
mation for future processing, although this requires considerable more stor-
REFERENCES
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These images should never be altered in any way, although they can be application. Compend Contin Educ Dent. 2008;29:432–449.
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