4 Laws That Ensure Better Clinical Photography by Dr. Glenn Krieger

4 Laws That Ensure Better Clinical Photography  

by Dr. Glenn Krieger

It’s been said that a picture’s worth a thousand words and for anyone in the dental field who has tried to explain treatment options to a patient, no truer words have been spoken. During my 29 years in practice, I’ve used pencil drawings on bracket covers, pointed at radiographs and done what look like hand puppets while explaining the difference between overbite and overjet. To date, nothing has been better at explaining dental problems to patients than clinical photographs.

Maybe it’s the ability for patients to see things through our eyes, or the shock value of truly envisioning their dental condition for the first time, but photographs have an impact on diagnosis and treatment planning unlike almost any other technology at our disposal.

However, if clinical photography is so important, why don’t we get much more training in school? Why do assistants—and many doctors—struggle so mightily with capturing exceptional images? Moreover, why have few really been taught how to use these images for better treatment planning and increased case acceptance?

When I crisscrossed North America teaching my clinical photography workshops, I worked with doctors who had $10,000 camera setups and those who didn’t know the difference between a DSLR and a “point-and-shoot.” No matter the experience level, I identified four distinct rules that, when followed, are almost guaranteed to help anyone get better images and increased case acceptance.

If you’re like most orthodontists, right now you’re more interested in the “right” camera or why your images are too dark or too light, but I assure you that if you learn the four “laws” of clinical photography, your images will one day be the best in the room.

Learning to do these things correctly and consistently isn’t fun, exciting or easy, but it will change your life … and your practice.

Law #1: Make exceptional use of mirrors and retractors

I know, I know: You want to simply buy a camera that will take great images right out of the box. Something that will allow anyone to pick up a set of retractors and get a great image every time. Well, I hate to be the bearer of bad news, but no such camera exists. Great images require great mirror and retractor usage.

Have you seen images that were way too dark even though you were sure the settings were right (Fig. 1)? Chances are, you didn’t retract the cheeks enough and that didn’t allow the light to get to the subject. Lips covering the teeth in the image (Fig. 2)? Yep, poor retractor usage. Not representing the Angle’s classification properly (Fig. 3)? You guessed it: poor mirror and retractor usage.

Clinical Photography
Fig. 1: Notice how much more difficult it is to see the second molar because the retraction and mirror placement didn’t allow light to get back there.
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Fig. 2: Improper use of retractors will cause the lips to cover the teeth, obstructing vital structures.
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Fig. 3: Improper understanding of mirror and retractors leads to an inaccurate representation of the Angle’s classification in images.

Truth is, if you want your patients to see their dental condition so they can accept it as a legitimate issue during the diagnostic phase and follow through with your treatment suggestions, you must have images that capture the teeth properly (Fig. 4). There’s simply no cheating this step. It takes practice and the right equipment.

Clinical Photography
Fig. 4: Proper placement of a retractor in lateral arch images allows better lighting of the arch and proper Angle’s representation.

What’s the right equipment? Retractors that allow you to maximally (and comfortably) move the lips out of the way (Fig. 5) and mirrors that fit the patient’s dental arch (Fig. 6) will help, but won’t guarantee better images. Many doctors use their “equipment” as an excuse for images that don’t meet their standards, but I can tell you that in many of my workshops, I’d use whatever mirrors and retractors were lying around and still get amazing images. Why? Because exceptional mirror and retractor usage is less about the actual equipment (though it does matter) and more about the positioning of the equipment and the patient.

Clinical Photography
Clinical Photography
Figs. 5 and 6: One of the greatest benefits of using larger mirrors and properly shaped retractors is the ability to get the cheeks and lips out of the way to see everything in the arch. Well-designed mirrors and retractors will not guarantee perfect images, but the wrong equipment could certainly prevent it. This is a “standard” set of plastic retractors and rhodium-coated front surface mirrors.

There isn’t enough room in this article to cover all of the positioning secrets and tips to get better images, but trust me when I tell you that poor positioning will hamstring even the best photographer from getting an exceptional image.

An example of proper positioning can be explained when one takes a lateral arch image. All too often we pull on both retractors—even the side that isn’t going to be in the image (Fig. 7). This keeps the “viewed” side from being stretched enough to properly capture all of the teeth. Had the operator simply relaxed the nonviewing side retractor to the midline, all of a sudden you can stretch the cheek much farther for a far better image.

Clinical Photography
Fig. 7: Overstretching the contralateral retractor in a lateral arch image will pull on the cheeks and limit how far you can retract the “working” side.

Proper usage of mirrors and reatractors will also allow you to get amazing maxillary and mandibular arch images. You just need to take your time and be diligent in the usage of your equipment. Great things will follow (Figs. 8 and 9).

Clinical Photography
Fig. 8
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Fig. 9

Be more deliberate with the positioning of the patient, mirrors and retractors and you’ll see the quality of images get much better, very quickly.

Law #2: Make time to learn in the practice zone

Does a high-wire act practice their new trick on a wire 60 feet above the ground with no foam pit? I sure hope not, or they’d eventually have problems. It’s been proven that all of us suffer in performance when we try to practice something new in the “performance zone.” The performance zone is just what it sounds like: the time when we are performing, and not practicing.

The practice zone is the place where mistakes are not only allowed, but encouraged. This is where, like an amazing chef, we get feedback and improve what we’re doing. Think about operative clinic when you were in dental school. Nobody told you to go pick up a handpiece, go into clinic and drill your first Class I on a live patient. You had ivorine teeth to practice with in the lab.

So, if the practice zone is where we get better, why do so many doctors throw their assistants into the performance zone—with a live patient—to get better at clinical photography? Maybe they’ve taken a course or seen a video on clinical photography and want to put these new skills to use. Great! Take a working lunch or make some time after the day is over to practice, practice, practice. Only when one has excelled in their photography in the practice zone should they move on to the performance zone and regular patients of the practice. If you jump into the performance zone and never take the time to practice in a learning environment, performance will always suffer and the images will never be what they could be.

Treat your photography skills the same way a high-performing professional sports team would treat their players, and give everyone lots of practice at a time when outcome isn’t so important.

Law #3: Be intellectually honest about your images

This is a tough one. Orthodontists are smart people who have achieved a lot. Naturally, it can be difficult to look at one’s work and consider it subpar, but that’s truly the first step toward getting better. I’ve received dozens (if not hundreds) of messages over the years from doctors who assured me that their images were “perfect” and they didn’t need much help. To date, I’ve seen only one set of images sent to me that didn’t need some sort of improvement. That’s OK, as long as we’re willing to learn to get better.

Like aligning teeth, our patients have a right to our best treatment, and images are no different. The funny thing is that for most doctors, getting from “decent” to “exceptional” only requires a little bit of tweaking of technique and a bit of practice. If that’s the case, then why do so many doctors struggle with getting exceptional images? It’s because they don’t know how to objectively measure the outcome.

When was the last time you got in your car, stepped on the accelerator, took a trip and never once looked at the speedometer? Did you drive on the highway and simply say, “This seems like the right speed”? Of course you didn’t. Your speedometer is an objective way of measuring your subjective feeling of speed. So, how do we objectively measure a subjective photographic image?

Define some criteria by which you can rate images and score each one. Some examples of things you could evaluate in an image of the lower arch could include:

  • Is the arch centered?
  • Is the entire arch visible?
  • Is one looking straight down on the arch?
  • Is the tongue not covering occlusal surface?
  • Do you see a dry arch?
  • Is the lower lip out of the way?
  • Is only the mirror image visible (not other teeth)?

Each category could be scored on a scale of 1–10 points. When you’re all done, add the points up and you have a score. You could easily pick the criteria you consider essential for every type of image and use that as your guide in a checklist. Let’s try this with Fig. 10.

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Fig. 10

  • Is the arch centered?
    9 points: It could be centered a bit better.
  • Is the entire arch visible?
    9 points: It’s missing a bit of the third molars.
  • Is one looking straight down on the arch?
    5 points: Arch appears “tipped back” a lot.
  • Is the tongue not covering occlusal surface?
    10 points: Tongue is completely out of the way.
  • Do you see a dry arch?
    9 points: Almost perfectly dry.
  • Is the lower lip out of the way?
    9 points: Almost perfect, but could be better.
  • Is only the mirror image visible (not other teeth)?
    8 points: You can see the reflected tooth in the image but it can almost be completely cropped out.

In this case, there were a total of 59 out of a possible total of 70 points. That’s 84%, which is a solid B, and that’s what I’d grade this image. It’s not amazing and not terrible. That’s the value of scoring images with your team.

Whenever I have a new assistant taking images, I have them do this exercise and rate their images first. Then I rate them and see if the ratings are close. If an assistant and I are within a point in a category, no big deal. But when I rate something a 3 and they rate it a 9, we have some calibration to do.

Law #4: Use digital co-diagnosis properly

I remember the first workshop I ever gave: It was 1999 in Bend, Oregon. It was such an amazing rush to watch attendees’ faces light up when they got their first great-looking image, and I left the lecture on a high note. Later, when I had time to reflect, I realized that I had indeed taught them how to capture amazing images, but hadn’t helped them to understand how to use these images for better diagnosis and case acceptance.

So, I started working on ways to use scripting to walk my patients through a process where I would use digital images to help them diagnose the treatment needs themselves. I had read some books on motivational interviewing, and thus was born digital co-diagnosis.

Let me explain how it’s different than regular diagnosis with a patient: If a patient has a large, failing amalgam, I could show them a picture and say, “See this big filling? It’s starting to fail and it’s so big that we can’t do another filling. So, we need to remove it, do a build-up and a crown.” Nothing wrong with that. Makes perfect sense.

Now, contrast it to what I would say using co-diagnosis: “Do you see this filling? Does it take up more than 50% of the tooth?” When they respond that it does, then I would reply: “So, what you’re saying is that there is more filling than tooth, right?” (I am actually agreeing with what they told me.) When they respond affirmatively again, I would follow up with: “So, since there is more filling than tooth, do you think the pressure of the filling had anything to do with this crack?” (showing the fracture line in my nice image).

You can do the same thing with improper occlusion, rotated or tipped teeth, partial spaces, odd smile lines and virtually any other orthodontic problem that exists. Instead of telling someone that their “bite isn’t right and needs to be corrected,” consider walking them down the path of understanding what the problem is and allowing them to discover the possible treatment options themselves (with some guidance, of course).

You get the point? You can tell a patient what their problem is, or you can show them an amazing image and help walk them down the path to true understanding of the problem and then—and only then—offer a solution. Patients will genuinely appreciate co-diagnosis and it’s helped my patients become my partners, both when I was a restorative dentist and now that I’m an orthodontist. But remember, it takes exceptional images and practice of the verbal skills (in the practice zone) to master this process.


Clinical photography has so many areas where we can practice to become better. From choosing a setup to camera settings, uploading images, intraoral images vs. extraoral images, setting up a studio, training our team, properly using images for documentation and collaboration and so much more, we could focus on almost anything (pun intended).

My Exceptional Clinical Photography course on the Orthopreneurs website goes into these elements in even more detail, but if you spend time on the four laws of clinical photography, and take your time understanding each step along the way, your images will be exceptional and your patient buy-in and case acceptance will skyrocket.

Tour the author’s office in our December issue!
In the December 2021 issue of Orthotown magazine, we’ll give readers
an exclusive look inside Dr. Glenn Krieger’s practice in Lewisville, Texas.
The issue is scheduled to go live at orthotown.com/magazine the first week
of December, and will land in mailboxes shortly thereafter.

Author Bio
 Dr. Glenn Krieger
Dr. Glenn Krieger graduated from dental school in 1992 and moved to Seattle in 1996, where he established a solo boutique practice. After 20 years as a restorative and cosmetic dentist, Krieger returned to residency to become an orthodontist. A diplomate of the American Board of Orthodontics, he maintains a private orthodontic practice in Lewisville, Texas.

Krieger has presented to thousands of dentists in North America, has been published in textbooks and dental periodicals, and has been named a “Top Clinician in Continuing Education” nine times. He also is the administrator of OrthoPreneurs, a group dedicated to helping orthodontists run their practices with an entrepreneurial bent.

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