The Power of Imaging and Imagery

The old saying that a picture is worth a thousand words is especially true in dentistry. About 70% of people are visual learners,¹ with dentists being even more so.² When dentists communicate with patients or peers, visual imagery is key to their success. Diagnosis, treatment planning, patient education, interdisciplinary collaboration, and practice promotion require effective imaging. You could say that what you see is what you get. Not getting that shortchanges you in terms of treatment outcomes, case acceptance, and practice production.

Digital Radiography
Dentists understand that imaging is fundamental to diagnosis and treatment planning. Without radiographs, dentistry would literally be practicing in the dark. Although conventional radiography has served dentistry very well over the years, today’s digital radiography is far better, and it surprises me that, as of this writing, just 60% of dentists in the United States use digital x-rays.³ My practice switched to digital radiography about 15 years ago.

The advantages of digital radiography are innumerable. Besides the savings realized in not having to use film and developing chemicals (and these cost savings let digital systems pay for themselves promptly), digital radiography affords superior diagnostics with image size, contrast, acuity, and magnification (Figures 1 and 2). Unlike radiographs viewed on lightboxes, digital radiographs give doctors superior diagnostics since they can be manipulated by their associated software.

Digital radiography also enhances patient communication. Prior to digital technology, holding up radiographs to operatory unit lights over patients and having them see what I wanted them to, never mind understand it, never worked well for me. I suspect this is the case for most doctors. By contrast, when having patients look at radiographs on a computer monitor while indicating conditions with a cursor, magnifying salient features, and enhancing sharpness or contrast, those images become powerful diagnostic and communications tools (Figure 3).⁴

Figure 1. A digital radiograph of this patient’s symptomatic tooth No. 19. This image initially suggested incipient periapical pathology at the mesial apex, but was not conclusive.	Figure 2. Adjusting contrast and magnifying the mesial apex using the digital radiographic system’s associated software helped confirm the diagnosis of apical periodontitis.

Figure 3. This radiograph, when shown to a patient with subgingival decay at her upper centrals (indicated by the cursor), helped her understand the need for core placement and replacing the existing crowns.

Moreover, this technology supports improved interprofessional communication and boosts interdisciplinary treatment. Copying film radiographs is problematic. Emailing digital radiographs to a specialist or a general practice in another state where your patient has moved makes such transfers much easier. The ability to look at and adjust images as clinicians teleconference about them in real time is enormously beneficial.

CBCT Imaging
Beyond the traditional views used in most practices, digital imaging has afforded dentistry cone beam computed tomography (CBCT). First introduced to America in 2001 (NewTom QR 9000 [QR, srl]), these machines (such as the Galileos Comfort Plus [Dentsply Sirona] and CS 8100 3D [Carestream Dental]) give us 360° of vision into our patients. Their advantages cannot be overemphasized! CBCT has revolutionized how we plan and execute treatment. It can tell oral surgeons whether impacted lower molars impinge upon inferior alveolar nerves or are merely superimposed on them by 2-dimensional panoramic images (Figures 4 to 6). It also can show endodontists accessory canals or hidden pathologies (Figure 7).

Figure 4. A conventional panoramic view of this patient’s mesially tipped and fully impacted third molars seemingly indicated that each tooth was partially contained within the mandibular canal.	Figure 5. CBCT revealed the exact location of these structures showing (in red upper left) that the mandibular canal was actually buccal to impacted tooth No. 17.
Figure 6. A similar scenario was noted with tooth No. 32 on CBCT scan.	Figure 7. CBCT in this case revealed radicular crazing at No. 19 (left arrows) and 2 canals in close proximity at the distal root of endodontically treated tooth No. 30 (right arrows).

CBCT technology is especially valuable in implant dentistry. CBCT scans are uniquely capable of identifying relevant anatomical structures, determining if a sinus lift is needed, detecting whether adjacent roots will impede implant placement, or selecting the size of a dental implant in a particular site (Figure 8). These scans, with their associated software (such as Simplant [Dentsply International] or CS 3D [Carestream Dental]), are also a tremendous aid in communication with the dental laboratory team.

Immediate protocols for implant dentistry are essential today. Demanding patients who require treatment in the aesthetic zone insist on them and will choose their practitioner on that basis. Looking at the effect of ClearChoice dental implant centers on our profession obviates this. CBCT scanning software can marry clinical images with intraoral impressions to fabricate surgical stents necessary for guided implant placement (Figures 9 and 10) as well as custom abutments with their provisional and definitive restorations.⁵ This is done using computer-aided design (CAD) and computer-aided manufacturing (CAM) processes, planning from the point of those restorations backward (Figures 11 to 13) as required in restoratively driven implant dentistry.⁶

Figure 8. CBCT imaging of this patient’s fully edentulous maxilla (shared online with a colleague during a teleconference) facilitates determination of the optimal locations for the 4 implants that will be used to support his complete denture prosthesis.	Figure 9. The CAD/CAM process first produces a virtual surgical guide using CBCT and impression scans before fabrication of the actual clinical guide that will be used during surgery.

Figure 10. When used during surgery, the CAD/CAM fabricated guide allows for precise implant placement.

Imaging for Communication
Intraoral cameras (such as the Schick USBCam4 [Dentsply Sirona] or the IRIS HD 3.0 [Digital Doc]) and still photography are vital to dental imaging for peer, patient, and dental laboratory communication, case documentation, and treatment acceptance⁷ (Figures 14 to 16). The first intraoral camera was analog, introduced in 1987 (DentaCam [Fuji Optical Systems]). In 2011, Dental Practice Report noted that 70% of American dentists had intraoral cameras, showing that doctors accept intraoral videography more than digital radiography.

Figure 11. CBCT and impression scanning provide a unified virtual model upon which the correct contours and position of the implant crowns (both provisional and definitive) can be first designed.	Figure 12. Next, the angulation path of the abutment was calculated.

Figure 13. Lastly, the position of the implant, based on the crown/abutment combination already formulated, was (virtually) identified.

Digital camera systems for dentistry were first introduced in 2003. Digital single lens reflex (SLR) cameras (such as the D7200 [Nikon] or the T2i [Canon]) have dental packages available from dealers like Lester A. Dine or CliniPix. Clinical still photography, despite its advocacy by many dental organizations, has never gained the level of popularity it deserves with American dentists.^8,9 Manufacturers’ representatives are your best source of technical training for these cameras. However, for clinical still photography or, especially, portraiture, courses such as those offered by Dr. Jason Olitsky at the Clinical Mastery Series are invaluable.

It should be noted that the smaller file sizes of intraoral camera images are often insufficient for some forms of communication. When specialists need to see intricate details of soft-tissue lesions or laboratories need shade information, digital still photography is inherently superior to an intraoral camera. The mapping generated by some of today’s digital shade matchers (such as SpectroShade Micro II [SpectroShade] or Zfx Shade [Zfx GmbH]) is advantageous to laboratory technicians who are tasked with matching the restorations to the lifelike look of adjacent natural teeth (Figure 17). They are extremely reliable and boast remarkable accuracy.¹⁰

Also, dentists who lecture and/or write clinical articles will need the higher-quality images of a digital camera. It has been my experience that print journals find the smaller file sizes from many intraoral cameras (as well as digital radiography software) inadequate for the production process. This is where these software platforms need improvement.

Promotional Imagery
When it comes to my finished cosmetic and aesthetic cases, clinical photography is imperative (Figures 18 and 19). Dental patients expect and only accept such treatment after seeing photographs of your own cases and computer simulations using their before pictures.¹¹ While stock before and after photos of cosmetic cases are available online (at shutterstock.com, for example), I believe it is far better to show patients your own work for credibility should resulting outcomes not match patient expectations created by stock photos.

Figure 14. A white lesion on the glossal border of this patient’s tongue was much more easily visualized with an intraoral camera than would have been possible using only a hand mirror and the operatory light.	Figure 15. Treatment recommendations are more easily accepted when patients can readily see how the structural integrity of their teeth has been compromised by crazing, as seen in this intraoral camera view.

Figure 16. Cervical caries often obstructed by the lips (especially on the lower) is easily shown to patients using an intraoral camera.

Figure 17. Digital shade-matching devices that generate maps for the laboratory technician to follow convey information for indirect restorations in an extremely effective manner.

An emerging area of dental photography is the use of post-treatment portraits. Professionally done photo portraits (Figure 20) of patients after the completion of smile design cases are powerful motivating tools for other patients in your practice who are considering cosmetic treatment. Having the entire face frame aesthetic cases humanizes this treatment, letting your patients see that their smiles are very important to their overall appearance.¹²

While I initially had these post-treatment portraits done professionally, in my experience, patients often did not follow up when referred to a photographer. Therefore, I decided to take this portraiture myself (Figure 21) by simply adding time to the regularly scheduled visits. This type of photo portraiture requires training and equipment. As previously mentioned, courses at the Clinical Mastery Series can provide the training, and the photography dealers listed previously can supply the additional gear.

These portrait photographs can promote your practice and increase treatment acceptance, especially online. In a June 2017 survey by Dental Practice Marketing and Management, 84% of all dental offices in the United States have a website. If you do not have a website for your practice, you need one now! Posting clinical before and after pictures on it with a post-treatment photo portrait will attract patients who are new to your area and are searching the web for a dentist. It will also reinforce the referrals by your existing patients of their friends, family, and coworkers who will likely peruse your website before calling your office. On our office site, we have a separate page (mcardledmd.com/smile-gallery) where clinical before images are on the left, after images are on the right, and photo portraits are centered between them.

Social media also makes these images indispensable to generating new patients and case acceptance. A recent study showed that more than half of all American dental practices use social media, mainly Facebook.¹³ Having a Facebook page in addition to an office website makes your practice cutting-edge and will attract younger patients. Facebook is very visual, and your aesthetic imagery will suit its format perfectly to inform potential patients of your services. It can also influence existing patients to finally go ahead with treatment. My Facebook page shows off our office atmosphere, my staff and I interacting with patients, and articles I have published as well.

Figure 18. Preoperative pictures using clinical digital photography serve as a sharp contrast to the postoperative images.	Figure 19. Striking post-op clinical photos educate patients as to their aesthetic possibilities, promoting case acceptance.
Figure 20. A professionally taken post-treatment portraiture, when combined with clinical before and after smile design images, frames the case outcome and shows the emotional effects of the completed clinical work.	Figure 21. Post-treatment portraits can also be taken in the dental office with the necessary training and setup that will foster greater patient compliance for acquiring this imagery.

Figure 22. Graphic files can be generated using these photographs along with your practice logo, catchphrase, and promotional themes to create marketing posters.

For internal marketing, posters can be developed from these images by savvy marketers with graphics featuring your practice logo and website (Figure 22). Such posters in our outside hallway and reception area can be viewed by patients arriving for their appointments or waiting for us to open in the morning or come back from lunch. These framed posters include the patient’s photo portrait on the left with clinical before and after images arranged one atop the other on the right with the above-mentioned graphics and a call to action. I often hear new patients say they want me to make their smiles like the ones out in my hallway. The impact this has on my case acceptance is invaluable.

Closing Comments
As is evident, imaging and imagery can have a dramatic and positive effect on your dental practice. Well-taken images can profoundly influence communication, education, awareness, and production. I’m sure the idea was not conceived with dentistry in mind, but nowhere does it apply more that image is everything.

Acknowledgement
The author would like to thank Dr. H. J. “Brud” Ludington (Portsmouth, NH), Dr. Nomith Ramdev (Dover, NH), and especially Dr. James Spivey (Portsmouth, NH) for their help in the preparation of this manuscript.

References

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Dr. McArdle graduated from Tufts University School of Dental Medicine in 1985 and has been practicing general dentistry on the New Hampshire seacoast ever since. He has served on the active medical staff in dentistry of Concord Hospital in Concord, NH, and on the board of directors of Priority Dental Health, the New Hampshire Dental Society’s Direct Reimbursement entity. He is a co-founder of the Seacoast Esthetic Dentistry Association (dentalesthetics.com), which is headquartered in Portsmouth, NH. He is the founder of Seacoast Dental Seminars (seacoastdentalseminars.com), also headquartered in Portsmouth. He has authored numerous other articles both nationally and internationally in major peer-reviewed publications. He can be reached at (603) 430-1010, via email at seda@dentalesthetics.com or drmcardle@seacoastdentalseminars.com, or by visiting mcardledmd.com.

Disclosure: Dr. McArdle reports no disclosures.

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