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).
Fig. 8
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.
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.
Conclusion
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.
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.