Pixel Perfect

Digital cameras are proving to be valuable assets in diagnostics and treatment — both inside and outside the mouth. We investigate the latest developments in intraoral cameras and the benefits of using digital cameras for extraoral photography.

Digital photography in dentistry, by way of intraoral cameras and single lens reflex (SLR) cameras, has proven to be an excellent patient education and case acceptance tool, thanks to the ability it gives clinicians to show patients exactly what they are seeing. These high-quality images can also be used in treatment planning, consultations and case presentations, for communication with labs, marketing and more.

“First and foremost, you bring the patient into his or her treatment needs with intraoral photography,” says Sheri B. Doniger, DDS, who practices in Lincolnwood, Illinois. “I always say, ‘seeing is believing.’ In addition to patient education on home care, intraoral images are able to show patients the depth and breadth of areas of concern, including leaking margins, cracked teeth and the presence of frank decay. These images are also great for supporting data for dental benefit companies.”

Vu Le, DDS, who operates a general practice in Foothill Ranch, California, adds that extraoral photography, likewise, bridges the communication gap between the provider and the patient. “The average person won’t understand what a fractured mesio-lingual cusp on number three means, but a photograph explains it very quickly,” he notes. “We’ve found that upon seeing a high-quality photograph, patients can often suggest the correct treatment themselves.”

Digital cameras capture images via an accumulation of picture elements, or pixels. Some intraoral cameras and most SLR cameras gather this information in megapixels for even higher resolution. And they do this while simplifying operation and improving quality, all of which is geared toward making image capture a snap. Le says that most of his imaging is done with extraoral cameras. And, in fact, he teaches other dentists to use extraoral photography to benefit their practices. “Extraoral cameras,” he explains, “excel at full-face, wider full-arch and quadrant shots. Intraoral cameras, sometimes known as ‘stick cameras’ are smaller and more maneuverable. They excel at single tooth close-ups. But I’d rather have a wider, higher resolution image in most cases. The value of wider perspective and context can’t be understated. I can get almost as much detail with a 16 megapixel camera taking a full arch image as I can with the typical 0.5 megapixel intraoral camera.”

A practitioner may, indeed, favor the use of one type of camera over another. But as prices continue to drop from the stratosphere, more dental offices may begin taking advantage of the benefits offered by both intraoral cameras and digital SLR cameras.


Point of Sale | Dynamic Duo

  • Benefits of using digital cameras in dentistry include improved communication between labs, other dental professionals and insurance companies.
  • Both intraoral and extraoral photography can be valuable assets in treatment planning, patient education, case acceptance, case presentations and marketing.
  • Intraoral cameras easily capture intraoral close-ups while maintaining patient comfort, and can show patients their exam onscreen in real time.
  • Single lens reflex (SLR) cameras are gaining ground for use in not only extraoral, but intraoral photography via the use of mirrors and retractors.
  • Some prefer intraoral cameras for their user-friendliness, while others prefer SLR cameras for their higher resolution and expanded images. Together, they make a formidable duo.

INTRAORAL CAMERAS

Intraoral cameras started out in the 1980s as bulky units that required the use of VCRs for viewing. They have slimmed down over time to become streamlined wands that can magnify crystal-clear images up to 100x and project them in high resolution onto a computer screen — in real time. They may connect to a computer through USB cables or docking stations, but wireless versions are increasingly available for ultimate portability.

“Portability is important to many clinicians,” says Doniger. “Utilizing a USB port, images may be taken in the hygiene operatory and then the camera may be moved to the restorative operatory, so one camera is more versatile in its function, and it does contain some costs.”

Many intraoral cameras allow one-handed operation, and feature auto-everything, including brightness, focus, and depth of field; offer freeze-framing and video modes; provide superior LED illumination; and are designed with small heads with antifog lenses to facilitate distal views in even the tightest posterior locations, while enhancing patient comfort.

According to Le, three intraoral camera modalities are currently available. “The conventional, visible light imaging is the most common,” he says. “Since that market is maturing, you are beginning to see pricing drop, with some producing very good images at a fraction of the original cost.”

Le notes that camera prices can range from $300 for a “good enough camera” that a practitioner may be able to afford to have in each operatory, to upward of $3,000. While higher-end intraoral cameras offer higher-definition images, faster shutter speeds to counteract the effects of shaky hands, and better diagnostic features, they command higher prices. In general, Le believes that intraoral cameras offering the best value on the market will run on almost any practice management software and come with US-based tech support and return policies. He notes that this is something that the cheaper cameras sold on some internet sites lack.

Another type of intraoral camera, Le reports, combines two modalities into one handpiece. One of these uses an interchangeable head system to go from intraoral imaging to fluorescence-based caries detection in seconds. Used with accompanying software, this technology reveals carious tissue in red. Another camera of this type integrates settings, including extraoral, intraoral and caries detection modes into one handpiece, and can even identify gingival inflammation. Due to a broad focal distance, both full-face and close-up images are possible with these units. Le says he finds these technologies especially useful as diagnostic aids.

The third form of intraoral imaging mentioned by Le relies on transillumination to reveal everything from cracks to caries — and often what a radiograph won’t pick up. Transillumination uses near-infrared light to expose inner tooth anomalies, in essence, allowing clinicians to see through the enamel. Unhealthy tissue will not allow light to pass through and will appear dark. Says Le, “This gives a unique, radiation-free way to visualize interproximal caries and fractures.” Because no X-ray is involved, this type of imaging can be especially helpful for treating patients concerned about radiation exposure.

Le wonders if the addition of diagnostic features will become a necessity for all intraoral cameras. “The disruptive pricing of some cameras and the onslaught of internet cameras make standard imaging intraoral cameras a tougher sell,” says Le. “Diagnosing caries or fractures may improve the value proposition for an intraoral camera. But if doctors wish to publish or present their work to peers then an extraoral camera would be a better choice.”

In fact, by some estimations, the biggest challenger to the intraoral camera is the extraoral SLR camera, which is enjoying more clinical use due to plummeting prices. Although the intraoral camera offers faster and simpler image acquisition due to the fact that no retractors and mirrors are required, new, lightweight extraoral cameras offer higher resolution. Some even can take pictures through cancer detection devices.


Terms to Learn

  • Margins: The area around a tooth where a filling or crown meets enamel.
  • Megapixels: A megapixel is equal to one million pixels.
  • Mesio-lingual cusp on number three: Refers to the forward-facing and tongue-facing occulsal edge of the first molar on the upper right quadrant.
  • Mirrorless camera: Uses a digital display system instead of a mirror and optical viewfinder.
  • Pixels: Picture elements.
  • SLR: Single lens reflex camera that uses a mirror reflection and prism to allow viewing of a subject for image capture.

EXTRAORAL CAMERAS

Regular SLR cameras can be used to complement intraoral camera imaging by capturing extraoral features from smiles and profiles to record alignment. But they are also being used to capture intraoral images.

Le says he realizes that some people still prefer the ease and agility of a “stick camera,” and that infection control is also more of a challenge with any nondental camera while intraoral cameras fit well with standard infection control protocols. He also acknowledges that there are more challenges in retraction, reflection and workflow with SLR cameras than with intraoral cameras.

“But,” he adds, “I can take a full-arch shot with my $600 extraoral camera, and zoom into a single molar, and still have more visible detail and more accurate color than I can with my intraoral camera. In fact, the most critical advantage of an extraoral camera is its color reproduction. When you are documenting subtle shades of pink gingiva, the superior tonal range can capture oral pathology accurately and diagnostically.”

Typical problems with photography include over- or underexposure, poor focus, and incorrect positioning that can distort images. Much of this, however, is being resolved through the countless auto features on these cameras. In fact, some manufacturers are now offering SLR cameras that are designed specifically for use in dentistry.


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Crossovers

Some manufacturers are tailoring single lens reflex (SLR) cameras to accommodate dental applications and everything from full-face and profile shots to intraoral macro shots. Vu Le, DDS, a practitioner based in Foothill Ranch, California, notes that three cameras currently bridge the gap between intraoral cameras and larger SLRs. One, priced at $900, comes with a close-up lens, a flash, diffuser, battery secure digital (SD) card, antishake mechanism, easy auto-focusing and auto-exposure, and increased depth of field.

Le also mentions a kit that contains a highly modified point-and-shoot camera. Included is a close-up attachment that allows intraoral photo­graphy, built-in flash, and a custom close-up lighting attachment that facilitates balanced lighting.

A third option is a small specially designed camera that’s reportedly easy to use, lightweight, user friendly, chemical- and water-resistant and easy to disinfect thanks to its medical-grade housing. It’s also said to offer simple one-handed operation, even with gloves on. It’s even HIPAA compliant, reducing the risk of violations, while safely and securely capturing and storing information. Various modes include “surgery,” which allows close-ups, “telemacro” for close-ups of a single tooth, and a “whitening” setting for shade correction, all translating to ease of use. But all this convenience comes at a higher price.

Most extraoral photographers make use of mirrors and retractors to take both maxillary and mandibular full-arch photos, as well as buccal and occlusal images.

Available kits might include macro lenses for close-ups, ring flashes and diffusers. Ring flashes are circular flash attachments that fit around a camera lens to diffuse light, which helps eliminate shadows, while providing excellent illumination of even posterior teeth. Flash diffusers can be attached to smooth out the light of a single point pop-up flash. Cross-polarization filters are also available to eliminate reflections on teeth.


WHAT TO LOOK FOR

As the technology continues to evolve, cameras for use in dentistry be­come more foolproof and user friendly. “I personally like cameras that allow for easy focus and capture, and high-definition (HD) imaging,” says Doniger, noting that HD images translate well to either an operatory laptop or a presentation screen in a consultation area. “The higher the resolution the better,” she says, “though that comes with a cost.”

But Doniger adds that those looking to purchase intraoral cameras for their practices should consider other camera features, not only cost. “Look for LED lights built directly into the camera head, as well as USB connectivity,” she says.

In addition, Doniger stresses that manufacturer support is another important factor. “Buy from a company you know and trust,” she advises.

Le agrees. “Many colleagues, disillusioned with expensive dental cameras have resorted to buying sub $200 cameras online. Support and return policies from overseas vendors should be considered nonexistent. If you require something that works reliably or a tech support department to help you, a cheap imported camera is not your best choice. On the other extreme, I do not feel that intraoral cameras can maintain wide acceptance at $6,000 either.”

For Le, the most important feature to look for is good image quality. “All intraoral cameras look great in controlled demo situations. A better demonstration of an intraoral camera is on a living, fog-breathing human being’s mouth. But the real torture test is to shoot a full facial shot with an intraoral camera. The small LED’s cannot work more than a couple centimeters away, so it forces the camera to use the room light and amplify. That’s when you’ll see which has the better sensor.”

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Le offers clinicians a series of questions to ask when considering a camera purchase. “Does the button give good tactile feedback? Does the camera shake when you push the button? How often do you get motion blur due to button pressure? Are the sleeves easy to attach and remove? Is the camera easy to grip in your hand? Will it work directly with your current practice management software, or do you have to use the included camera’s program? If it’s the latter, can you easily transfer the images to your patient management system? Is the USB cable replaceable? Is the case well sealed? Does it resist bending and flexion?”

But sometimes it just comes down to preference. Doniger says that the intraoral camera used in her office hits all the right notes. “But,” she cautions, “each clinician should try the camera out before buying to see what fits into his or her practice and his or her hands.”

Says Le, “A well-configured SLR or mirrorless camera is, in my opinion, the best way to get truly publication-quality images in the dental office. But it’s not for everyone. For a busy office where you want the hygienist or assistant to take quick photos for patient education or insurance claims, an intraoral camera may be a faster and easier alternative.”

In Le’s opinion, well-informed sales representatives will have the most success identifying needs and matching them with the right solutions if they have a large portfolio of products and services to choose from. “In the long run, matching a customer with the right solution for his or her individual needs will be the best for everyone involved,” he says. “Listen to your customer’s needs, and what the images will be used for.”

If you do that, you’ll have the best shot at ensuring your clients’ images come out pixel perfect every time.

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Featured Image by SERGEYRYZHOV/ISTOCK/GETTY IMAGES PLUS

From MENTOR. February 2018;9(2): 34-38.

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