As a technology consultant, I work with many dentists who have a variety of questions regarding the addition of technology to their dental practices. Many of the questions are related to topics that I have previously written about in New Dentist magazine: an overview of how to decide which technologies to purchase, how to choose dental software, and digital radiography. The topic that seems to receive the most attention, and the most confusion, is digital photography and digital images in general. The sheer number of choices perplexes most dentists. This article will examine a number of issues that need to be answered when adding digital imaging to the dental practice. I will explore the pros and cons of both intraoral and extraoral cameras. I will examine the criteria that dentists should use in picking a digital camera for their office. I will also look at the software choices that exist for storing and manipulating these images. It is also important to delve into the myriad of options for digitizing existing non-digital images. Finally, we will look at the choices for storing these images, and printing and other options for sharing these images with other people, such as the patient, insurance companies, and other dental colleagues.

Intraoral Cameras

Intraoral cameras have been used for dental applications since the early 1990s. One of the first products was the AcuCam, made by New Image Industries. At one point, New Image held over 40% of the market share for these systems. For many years, intraoral cameras were the cameras of choice. Although there was a bit of a learning curve, they were relatively easy to master and still have widespread acceptance today. Recent surveys have shown that intraoral cameras are found in about 50% of all dental offices, which seems to indicate that they may have reached their peak in this regard. Anyone that has used an intraoral camera is aware of the advantages that these systems offer:

1. Most cameras are capable of magnifying images at 40-52X normal. This can be an invaluable tool in allowing the dentist to see pathology, such as open margins, fractures, and caries, that wouldn’t easily be seen without this level of magnification.
2. The ability to have images on a computer monitor screen that is visible to the patient is a large benefit. Most experts agree that one of the keys to improving patient acceptance to our treatment plans is the concept of “co-diagnosis”. In other words, allowing the patient to see the problems that we see will allow them to participate in the diagnosis of their dental problems, and they will then be more inclined to accept our recommendations for treating problems that they may have been previously unaware that they had.
3. The cameras allow us to have a permanent record of a patient’s condition before we begin treatment. This can be quite beneficial for cosmetic cases where we can show patients before and after photos of their teeth. Also, for legal reasons, it will often be valuable to have a record of a patient’s condition before treatment began, just in case the patient is unhappy with the results and is considering legal action.
4. The cameras can be used to take photos of x-rays, which frees us from having to send in our original radiographs to the insurance companies. Also, adding photo documentation to an insurance claim will often speed up the approval of that claim.


When evaluating intraoral cameras, there are a number of factors to consider. I would highly recommend that anyone considering the purchase of an intraoral camera should attend a dental meeting where many of the different vendors will be on hand, so that you can evaluate the different aspects of the cameras:

a. Ability to handle multiple views. According to Clinical Research Associates, there are 6 standard intraoral camera views that should be evaluated when choosing a camera. These are divided into intraoral and extraoral views. The intraoral views are the distal of the upper last molar, the buccal of the upper last molar, and the lingual surfaces of the lower anterior teeth. As far as the extraoral shots are concerned, test the camera’s ability to take a full lower arch, a full-face photo, and a photo of a bitewing radiograph that is being lit by an x-ray view box. Test all of these shots to see which camera can handle the majority of them with ease.
b. Portability. Many dentists have large offices and to save costs, they will consider using a camera that can easily be moved from one operatory to another. Do not fool yourself into believing that if a camera system is on a large cart that you will easily be willing to wheel the cart from room to room; I tried it myself years ago and it just doesn’t work! Some of the more popular models that allow for this are manufactured by Digital Doc (Digital Doc Inc.), AcuCam Concept IV (Dentsply-Gendex), the Quick Cam (Video Dental Concepts), ViperCam (Integra Medical), and ImageCam (Dentrix).
c. Ease of focus. Does the camera require manual focus or is it autofocus? Most cameras have an adjustable focus, so you should evaluate how easy it is to change the focus. The focus should be well labeled, and should have a range of motion that is less than 100 degrees so that you can easily change the focus setting with one hand.
d. Built-in freeze-frame. Many of the older models do not have this feature, and most people prefer this element to be included with the system.
e. Capture button location. Most units use a foot pedal to capture individual images, but other models have the capture button right on the handpieces. For many dentists, this is simply a matter of personal preference, so you should try both types of systems to see which feels most comfortable for you.
f. Single lens system. Many earlier systems contained two wands, one for true intraoral photos (90 degree lens) and one for extraoral photos (0 degree lens). Many of the newer systems now use one wand for both types of photos. Since you may want to use the camera to take photos of x-rays on a view box, the key factor is the ability of the camera’s built-in light to be turned off when taking these types of photos.
g. Maximum number of images displayed. The standard number is 4 images that can be displayed simultaneously. However, I’ve seen systems that only allow 1 image at a time, and other systems that can allow 16, 20, or 25+ images to be displayed.
h. Unique features. Most camera manufacturers will add special features to their systems to differentiate themselves from their competitors. Some of the features that you will see include flexible cords, extraoral light adjustments, printing from a portable unit, light and color adjustments, and image scrolling through the foot pedal.

Extraoral Cameras

While intraoral cameras have many benefits, there have always been some roadblocks for dentists who wished to use them in the office. As I stated earlier, there is a learning curve associated with their use; most have an upside down image and so using them is similar to using a mirror in the mouth. The earlier units had a tendency to fog up, and you need to use a disposable sheath between every patient. The units also tend to still be on the expensive side, and better models still sell in the $5,000-7,000 range for the basic system. What most dentists wanted was a way to use cameras that they are already familiar with, which is the extraoral camera. The problem, for a long time, was the unavailability of digital cameras. While there are many ways to get traditional photos into a digital format (more on that later), it is still much more desirable and easy to have digital images from the start.

When the first digital cameras for consumer use were introduced, they were very expensive and while suitable for the home, they did not meet the criteria for producing diagnostic dental photographs. The first units that came out were 1.3 megapixel cameras. Since then, we have seen 2.1 megapixel units, 3.3 megapixel units, and lately, 5 and 6 megapixel cameras. Since the issue of pixels is often misleading and confusing, here is a short primer on pixels:

It helps to remember that pixel count doesn't determine how good the
image is -- only how big a good print you can make! Image quality is determined more by lens quality, the imaging chip and its control circuitry, etc., not to mention the ability of the photographer to control those factors. To put the "how big" issue in some kind of perspective, the rule of thumb I use is that (with a continuous-tone print device such as a dye-sub or good quality ink-jet printer) you need to provide 300 pixels per inch in the print to provide "high quality" photographic results -- ones that will stand up to close
scrutiny and still look photographic. If you can settle for "snapshot" photo quality ie images that will be examined casually at normal reading distance or better, then you can get by with 200 pixels per inch in the print, and for "display" quality, meaning prints that will be viewed from several feet away, you're OK with 100 pixels per inch or even less. (Keep in mind that these quality levels are strictly my own personal preferences... some
people might be perfectly happy with 50-pixels-per-inch images!)

Anyway, if you've got a 2-megapixel camera (typically about 1200 x 1600
pixels in the image) the biggest print you can make and retain what I think
of as "high quality" is 4 x 6 inches. A 3-megapixel camera (let's
assume it'll be 1500 x 2000 image pixels) will let you make a print of 5 x
7 inches at the same "high quality" level. That's a difference of about
an inch each way. If your usual need is for "snapshot" quality, you can bump up these figures by 50%... but either way, I think it makes it pretty clear that the 5 and 6-megapixel cameras won't make a BIG difference, unless you plan to print 8 X 10 photos; the image on the computer monitor screen will look the same whether you are using a 2, 3, or 6-megapixel camera. Or to put it another way, if you have a choice of a 3-megapixel camera that's perfect for your needs and preferences, or a 6-megapixel camera that would force you to compromise on the features and controls you want, don’t buy the 6-megapixel model just because it has more pixels!

When you are evaluating digital camera systems, I would recommend that you work with a company that specializes in systems designed for the dentist. Two well-known companies are Photomed and Lester A. Dine. Both produce systems that include all the hardware and software that a dentist would need to get started in digital photography, although they take different approaches and have subsequently different costs of their systems. The Photomed systems are typically 3.3 megapixel cameras with all components included, such as macro lens, flash diffuser or ring flashes, memory cards, and battery charger. These systems normally start around $1800 and can go as high as $6000 depending on the camera type and attachments that you purchase. The Lester Dine system, by comparison, modifies the flash next to the lens for the appropriate amount of macro lighting, so no ring or point flashes are needed. Their systems also use a 3.3-megapixel camera body and costs run from about $1700-2500, depending on the model.


From Analog to Digital

For many dentists, the transition to digital photography is exciting and opens up many new possibilities for them. The difficulty for most, however, is trying to figure out how to digitize their current photos and slides. There are a number of methods of getting your prints and slides onto a computer, where they can then be manipulated and output to different sources:

1. Photo or Picture CD. For film that hasn’t been developed or with negatives, you can ask the photo developer to put your images on a Photo or Picture CD. These CDs can be read by all but the most ancient CD-ROM players, and can then be downloaded onto your computer’s hard drive.
2. Scanner. This is currently the only method for getting existing photos or slides into a digital format. I would recommend that when you search for a scanner; find one that has both a backlight and a transparency adapter. Models that I have found to be particularly good are the UMAX Astra 4000U and the Epson Expression 1600 Professional Series. You should look for a scanner that has the highest dpi (dots per inch) resolution that you can afford. Better models have at least a 1200 X 2400 dpi; the Epson, for example, has a 1600 X 3200 dpi resolution.
3. Online. There are numerous online companies that offer online storage and scanning of existing photos. Kodak PhotoNet (soon to be replaced with their Picture Center Online on 2/14/2002) is an excellent way to store digital images, although they don’t offer scanning of existing photos. While these online services are an option, they are hardly the cheapest! Expect to pay from $1-10 per scan, which can get very expensive if you have hundreds of photos and slides to be scanned.

Once you find a method of getting your analog or digital photos and slides on to a computer, you need to have some method of storing, cataloging, and manipulating these images. The only method before true integration became a reality was to use a stand-alone image management program. Some of the better and more popular ones are Vipersoft, Dicom Imaging Suite, Tigerview, and SciCan Image FX. As dental practice management software has evolved, there was a need to find a way to integrate these image databases with the management program, so most of the developers of these programs built “bridges”. Most bridges, however, are still one-way, in that you can call up the image management program from the patient screen, and all that patient information will already be transferred. However, this method does not allow images that you capture to be transferred back to the patient file in the practice management program. To accomplish this, you need true integration. This type of integration is found with some of the more prevalent programs, such as Dentrix DDO, Softdent Powercase, and Eaglesoft One Patient Record.

Output

Once you have access to your images and have manipulated them to your liking, the final piece in the puzzle is to determine how you want to output these photos. Obviously, this will depend a lot on how you plan to utilize the images, such as patient presentations, dental lab communication, lectures, insurance documentation, or online collaboration. Some of the various choices include:

a. Inkjet printers. It is important to use a printer that is not only capable of printing medical quality images, but using the right paper is also important. An example of a good quality printer is the Kodak 1200 Desktop Medical Imager, which lists for about $450. The paper and supplies will tend to be more expensive for these type of printers; ink cartridges run about $50 and a high-quality paper costs $.50-60 per page.
b. CD Writer. Most new computers come with CD burners, known as CD-R and CD-RW drives. These drives are capable of writing the images (or any other files you designate) directly to the CD-ROM, so that you can easily send the CD through the mail or make backup copies for yourself.
c. Removable media. There are many types of removable media that can be used, depending on the amount of storage capacity that is needed. Some of these options include floppy discs, Zip disks, and tape backup.
d. Email. Once you have a digital image, any email program will allow you to attach files to be emailed. You should ensure that the images are in a standard format that can be read by other programs, and just as importantly, that the files are compressed. An image created with a 3.3-megapixel camera can be many megabytes in size. Converting this to a JPEG file (these are files that have the .jpg extension on the end) will reduce them to 500-750 k on average. Keep in mind that most people still use a dial-up connection to the Internet, and downloading large files can be very time-consuming, so compressing the images makes a lot of sense.
e. Online collaboration. There are many services that will allow you to upload your digital files to a site that will store and catalog these files for viewing by other people. The most basic ones, which are not necessarily designed for dental applications, are quite easy to use and most are free of charge. Sites that are built around online dental collaboration, such as Transcend Online, are excellent for this purpose, but expect to pay about $800/year for this level of service.

The world of digital photography has continued to grow over the past couple of years, and this is to the advantage of the dentist. Prices will continue to drop, image quality continues to improve, and the products and systems are becoming easier and easier to use. For any dentist considering the addition of digital photographs to their dental practice, the time to take the plunge is now!