It is possible to take a series of clinical photos with a smartphone. As long as you know what you can do with a smartphone and why it can't be used for everything.
In 2008 I started taking clinical photos on all new patients and on all patients I developed more comprehensive treatment plans on. For the last 6 years of my time as a practice owner, it was my team members who took 90% of all photos. They used DSLR cameras to take the photos and were able to get ready for- and take a full series of clinical photos in about 3 minutes. All this without any assistance.
Taking photos with a smartphone is not so different from using a DSLR camera. Except that it's much easier to get started with a smartphone.
In this post, I'll review:
How to use smartphones to take clinical dental images.
What some of the differences are between DSLRs and smartphones and how this plays out.
Which retractors and mirrors I recommend and why.
An app that makes it easier to work with clinical photos.
Efficiency or perfection?
The photos below are taken with an iPhone 11 pro in combination with a SmartLite MDP. The photos were taken by a business coach who had wandered into one of my photography courses.
It was her first dental course.
She had never taken clinical photos before (or seen any).
She used the Dental Shooting photo app (you can find links to the app for both android and iPhone on our website). The app guides the photographer to take the photos correctly.
Overall, it took her 2 minutes to take the series of photos.
When choosing between DSLR or smartphone, I think it's important to make up your mind which is more important to you:
Getting the photos you need
To take photos of sublime quality - no matter how long it takes to learn and to put into practice.
Are the images acceptable?
It depends on what they are to be used for.
There is no doubt that these images are beautiful, shot correctly with the right angles (almost) and cropped correctly. Overall I would say they are better than average.
But:
The images are distorted by the phone's optics.
For reference, I've included a photo here, of the same patient, but taken by my dental assistant with a DSLR camera and a dual flash. Here you can see how the dental arch has a more natural shape, rather than the highly compressed one you see in photos taken with a smartphone.
This is due to the use of a rather powerful wide-angle lens on all smartphones. The powerful wide angle allows you to get some great outdoor shots and sometimes indoors. The wide angle extends the camera's ability to capture a lot of information that would not be possible with a regular lens. But the consequence is that the image gets distorted a bit. The greater the distance between the camera and the object you want to photograph, the less significant the distortion becomes. But when you take a photo quite close to an object, as we typically do in dentistry, the distortion starts to become very apparent.
On the images shot with an iPhone. You clearly see the distortion on the extraoral photos, as well as the intraoral frontal photo. (The center becomes large while the sides are pressed together around the center - large nose + narrow face (even narrower than normal) - intraorally 11 and 21 (number 8 and 9 for the americans😊) become very large while the sides are compressed)
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DSLR camera
When taking photos with a DSLR camera in a dental practice, it's usually with a 60- or 100mm macro. That way you avoid any kind of distortion. This gives the most realistic photos, as well as the quality being good enough to be magnified up to a very high magnification (unlike smartphone photos).
Another advantage of photos taken with a DSLR camera is that you can work with a fixed magnification on your photos. This means that all photos are always the same size and cropped the same way. This results in images that require minimal post-processing. Occlusal photos taken with a mirror need to be flipped and perhaps a photo taken on the vertical needs to be rotated. But that's it.
So with a DSLR, you have the images as they should be within the first shot. The challenge is that there is a very, very steep learning curve to get started using a DSLR camera.
DSLR cameras require you to know about different settings and remember how to use them from time to time (So it's not harder either, but it takes a lot of practice and maintenance to make sure you remember the settings and get it right every time).
The camera and flash is heavy and difficult to manoeuvre with.
In other words, it takes a long time to learn and get started. But once it works, the overall photo workflow is faster to work with than the smartphone. Just as it provides better image quality.
Smartphone photos
Photos taken with a smartphone usually need a lot of processing after they've been taken.
It takes time to post-process the photos. In this way, the overall workflow can take longer. Apps such as dental shooting make this easier and faster. But you don't avoid having to edit the images.
Unlike DSLR cameras, the learning curve with smartphone + photo app is often quite low.
So you are quickly up and running. But on the other hand you have to spend a longer time cropping and changing the magnification.
Especially if you want to show beautiful before-and-after photos, using a photo app on a smartphone is challenging and time-consuming. But for small pieces of documentation or prior to a clear aligner treatment planning, it can work well enough. Again - depending on what you're going to use the photos for.
Daily training a necessity
The most important thing when implementing clinical photography is to take a lot of pictures. This is true whether you take photos with a DSLR or smartphone. If you practice daily and accept that on your first 50 patients, the pictures will look anything but perfect. You will become good at taking clinical photos... This is the price of getting good at taking pictures - but it pays to keep at it.
To find out how you can set up a workflow so that everyone in your team gets good at taking clinical photos, read this post.
Practical details
Equipment
Good photos are much, much easier to take if you have the right equipment.
With inappropriate equipment, it can be downright impossible to take useful photos.
The equipment I recommend is chosen to enable you to have a simple workflow that allows everyone in the team to take a full series of clinical photos in about 2 minutes without assistance. In other words: There are all sorts of different pieces of equipment that, in their own way, can help improve quality. Again, it's important to focus on what you need the images for, how quickly you need to be able to take them, to suit your workflow and temperament. After all, it's no good being able to take the world's best photos if you have to spend 2 hours doing it yourself in a specially designed photo studio, if you're experiencing a financial loss of a fortune.
When I advocate that it should be possible to take the photos in 2 minutes without assistance, it is because working alone increases flexibility and reduces the risk of bottlenecks in the other workflows of the practice.
Intraoral frontal and buccal photos:
Short straight retractor with a lip holder that has a somewhat smaller diameter than those you can generally buy at the dental depots.
The smaller diameter makes it much easier to take pictures on all types of patients ( both patients with large and small mouths). It is also easy for patients to hold the retractors correctly themselves.
In addition, it is possible to use the retractor to pull the lips back one side at a time, creating space to take the buccal images without the use of mirrors.
In general, we are not very enthusiastic about buccal photos taken with mirrors. For one thing, it's super difficult to take the photos so they turn out well (read: better than just with the right retractor). Secondly, it hurts the patients when they have to have the buccal pictures taken with a mirror.
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Occlusal photos
1/4 self retracting retractor
It is somewhat different from the other self retracting retractors on the market in that it has had a section cut off to allow plenty of room to insert the mirror into the patient's mouth. In addition, the shape allows the patient to hold the retractor correctly in place with one hand.
Titanium mirror with handle.
The mirror we use has a shape that makes it easier to place correctly in the patient's mouth.
In addition, the mirror has a handle attached. The handle makes the mirror much, much easier to place correctly for the photographer and to achieve the correct angle between the mirror and the camera.
NOTE. It is ALWAYS the photographer who holds the mirror. Because if the patient holds the mirror, the mirror will not be positioned correctly and will not go far enough into the mouth for the photographer to get all the teeth properly in the picture. Moreover, it is almost impossible for the photographer to get the correct angle between the mirror and the camera.
With a handle on the mirror, all this becomes SO much easier. Once you've tried taking an occlusal photo with a handled mirror once, you won't want to go back. Believe me, I experience it on all my hands-on courses when participants try it for themselves. It's a great aha experience.
The mirror is a so-called titanium mirror. It reflects up to 80% of all light and thus requires less light than the classic chromium mirrors, which only reflect about 60% of light.
It is also possible to buy the very expensive rhodium mirrors or high gloss polished steel mirrors. So far, I just haven't seen the option to get them with a handle. That's why I don't recommend them yet.
Hot water
To avoid fogging of the mirror - and to make it easier and more comfortable for the patient to have the retractors placed in the mouth - mirrors and retractors are brought into the surgery in hot tap water. When the mirror is removed from the water, it is dried with a microfiber cloth or large piece of gauze before being placed in the patient's mouth. This avoids both dew and water droplets on the mirror while taking pictures.
The equipment shown has been specially designed and imported to Europe by AlignerService. It is some of the equipment my team and I used ourselves through 6 years in my own private practice. AlignerService has chosen to import the equipment to make it easy and affordable for European dentists to get hold of equipment that is thoroughly tested, works super easily in practice in the workflow I have described earlier and which I teach internationally.
If you are an american colleague and want to know where to purchase this equipment. Please send me an email and I will send you my recommendations.
Light
Any camera requires large amounts of light,
both to be able to find the point you want to focus on and thereby take a sharp picture. And to reproduce the details of the surface you're photographing.
Of course, you can buy the best light source for a smartphone, such as a SmartLite MDP2 from SmileLine. With it, you get lifelike light and can adjust the light to make your photos more beautiful... but if you're into that, you should upgrade to DSLR instead. Here you'll find a myriad of options for making really, really great photos - the question is: When is it good enough for what you need your photos for?
So less can do it too. You can find relatively inexpensive ring flashes for smartphones to start with. Once you've implemented your workflow in the practice and figured out what your requirements are for your photos, you can always upgrade from there.
Patient Positioning:
We made sure to position the patient in a place where we could take all the photos at once.
My recommendation is to put the patient on the dental assistant's chair, with their back against a uniform-coloured wall. This way, the patient is optimally positioned to have photos aligned with the horizontal plane (this is extremely difficult if the patient is sitting in the dental chair).
In addition, you get a uniform background with no distracting elements. This makes it easier to analyse the patient's face and makes the images much nicer to look at. If you are later allowed to use the patient's facial before and after images for your marketing.
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With the patient placed in the dental assistant's chair, we took a seat in the dentist's saddle chair. This allowed us to more easily adjust our own height in relation to the patient's height, while providing a more stable starting point for taking the photos.
For all shots, we let the patient move while we staid in the same place.
Frontal and buccal photos
So after taking a picture of the face from the front with and without a smile, we asked the patient to turn 90 degrees and look at a point on the wall at the other end of the surgery.
We then moved closer to the patient and placed the regular retractors and instructed the patient how to hold them themselves.
First we took the frontal photo and then the buccal photos, by letting the patient turn the face to one side and the other respectively. While turning the face, we instructed the patient to pull the retractor a little more on the side we were going to photograph and to relax a little more on the other side until we could get a photo with approximately a 90 degree angle of the first molar. This way we avoided taking the buccal photos with the mirrors.
The occlusal photos:
Here we placed a 1/4 self retracting retractor in the mouth of the patient and instructed the patient to hold it by himself with one hand. Meanwhile, we dried the mirror and placed it correctly in the patient's mouth. It was always the photographer who held the mirror. Only in this way is it easy to achieve the correct angle between the mirror and the camera, while at the same time getting all the desired detail into the picture.
An important detail:
Don't spend too much time trying to get the perfect shot. It's really hard for patients to hold their mouths open while they have to pull on their lips and we push a photo mirror into their mouths.
So when you take your photos, my recommendation is that you think about how you want your photo to look just before you start the process of taking the picture. Then, with focus and purpose, put your retractors into the mouth of the patient - brief instruction - focus - shoot ( if necessary 2-3 photos in quick succession) - move on to the next photo.
Data transfer
Once you've finished taking the photos, you'll need to find a quick and easy way to transfer your photos to your practice management software and the other types of software where you'll be using the photos. Personally, I prefer to be able to transfer the images directly to my practice management software first and then move them to, for example, smile design software or clear aligner software. Because that way I am in control of the images and not a third party vendor where you might have doubts about compliance with data protection legislation (GDPR / HIPPA).
In our dental practice, the camera was physically connected to the computer used for our CBCT X-ray machine. Because it was the most centrally located computer, it was not in use all the time and thus could be used for the purpose. All the photographic equipment also had its permanent place next to this computer. This way we could set the camera to upload photos to a dedicated folder on the clinic's server. Once the photos were uploaded they were deleted on the camera immediately.
From the server, all other computers in the practice had access to the photo folder. This allowed anyone with a password to our computers to pull the photos into the practice management system. With the images in the practice management system, the images on the server were deleted. The images were then rotated and mirrored to the correct position in the practice management software. (Note it is rarely possible to edit photos taken with smartphones to an appropriate extent in practice management or x-ray software. So it has to be done before importing them. Either in the phone or in some image processing software. On the other hand, you can often transfer the images wirelessly to the computer you're sitting at, making it easier to handle data transfer without having to move around a server.... as you can see, you'll need to find a good solution for your dental practice here. My recommendation is that you think about the whole workflow, so that it becomes an easy and smooth process from you locate the equipment until the images are transferred to the system and the equipment is stored correctly again)
We have to accept that it takes a long time to learn to take good photos. The pictures of the first many patients don't look very good and that's ok. Because that's the road we all have to go through to become good at taking the pictures.
In our office we practiced different skills 4 hours a month. Including how to take clinical photos. Less can do it too, you just have to be aware to constantly train your skills.
I have described how my team was successful in taking clinical photos. Now it's your turn to take action. You'll probably find your own little tricks to get the best shots possible. That's super cool, because it shows that you're gaining some experience and are figuring out how it works best in your hands.
Of course, if you need any help, feel free to write or call me.
Have fun with your implementation
Kind regards
Jesper Hatt DDS
Phone: +41 78 268 00 78