About a month ago (mid-June 2017), I attended an event hosted by the BACD (British Academy of Cosmetic Dentistry) for the first time since joining as a student member earlier this year.

I had a great day, learnt a lot about dental photography and met some great young dentists/students so thought I would write this feature post to share my experiences and some of the great things I came away with.

One of the best bits about it all was that it was basically free!! I just had to pay £1 to confirm my spot and that money went towards the BACD President’s chosen charity 🙂

Before I tell you about my day, let me tell you a bit about the BACD and how you can get involved too!

The text  in blue below is taken directly from their website’s “About the BACD” section…

“The British Academy of Cosmetic Dentistry was formed in November 2003 by a group of dentists, many of them leading practitioners in the field of cosmetic dentistry, who saw a need to share their knowledge with others. The aim is to create a dynamic, active group of dentists and laboratory technicians; however, the role of all other members of the team – hygienists, practice managers and assistants – in the overall aesthetic experience are equally important.

We plan to create an environment where everyone can come together to share their knowledge and experiences so that everyone can become better at what they do – regardless of their level of prior knowledge. Currently, any dentist can offer cosmetic dentistry irrespective of their training or experience beyond the basic dental degree. There are no specialist qualifications and no specialist register. Techniques constantly progress and the public is becoming increasingly dentally educated and discerning so it’s essential to stay up-to-date.”

If you’re a UK dental student reading this then you can also sign up to be a BACD Student Member via their website – it is very reasonable at £30

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The BACD invited a fantastic dentist who is based in Sevilla, Spain to come and lead the day: Dr Silvestre Ripoll

Despite Dr Ripoll’s first native language being Spanish, he spoke very good English! How many native English speaking dentists (or someone from any other profession) would be confident flying to a country where they speak another language and deliver a full days’ worth of teaching in that ‘foreign’ language?!?!

He is a specialist periodontist and a highly skilled with dental photography, which is interesting since you may not expect for a perio specialist to be needing to take as many photographs of their work, as I guess it is more relevant with restorative dentistry…?

You can check out some of his clinical photographs that are showcased on his website

Silvestre has a degree in Dentistry and a masters in Periodontology both from the University of Valencia (where he is originally from). He moved to Sevilla in 2001 where he set up his private practice.

As well as working at his own clinic (his practice is limited to perio and implants), he teaches at the Universities of Sevilla and Valencia – lecturing about periodontics and implantology.

Here is the official description for the event:

Dental Photography: Theory vs. Art

An opportunity to spend a day with one of the most creative and inspiring dental photographers in the world.

Dr Silvestre Ripoll will be sharing the basics of image capture as well as the secrets behind taking the most advanced, detailed and creative photos possible.

The day will comprise of both lecture and demonstrations so that you will be able to gain theory, as well as the set up necessary for advanced photography.

This promises to be in inspiring day, with many tips available to improve the standard of your clinical photography

The event took place on a Friday in June and luckily I had a free day in my calendar. So when I saw the event description on the BACD website and that it was a free event, my ears perked up – especially since the focus for the day was dental photography, which I have recently become interested in.

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Just a few months ago I bought my first DLSR! I’ve been wanting one for a couple of years now but didn’t have the money so was saving up to get one. FYI: I have a Nikon D5600 (I will make a separate post about this camera and why I chose it specifically).

Of course, I must stress that as a relative beginner with photography, I am not so much focussing on dental/macro photography initially – my main passion is actually urban/street photography, so living in London is perfect! I love the symmetry, the bleakness, the cityscapes, the rays of sunshine piercing between buildings to illuminate just a sliver of the street, I love the constant motion (and how it can be captured by playing around with shutter speed) – so, for now, I will be enjoying learning the fundamentals of photography by walking through London with my camera strapped around my neck just messing about with the settings 🙂

Hopefully as I learn more about dentistry, more about photography I will be able to incorporate macro photography into my practice, but for now, as a second-year dental student I have a lot more important things to be prioritising, like how to prep a DO on an upper molar, how to properly angle my probe when doing a basic perio exam etc etc…basically I need to first master the basics of practical dentistry!!

Don’t run before you can walk!

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Having said all that, I learnt so much from the day – I made 6 pages worth of notes and here’s some of it summarised…

There was a good turnout. I’d say roughly 60 attendees (most of them were dentists, perhaps only 3 or 4 other students were present). The event was hosted by 3M at their headquarters in Bracknell, a town in the leafy forested area ~35 miles west of Central London. Some of the attending dentists had travelled from places as far as Scotland to learn more to better their own practice (and grab some extra CPD hours).

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After introducing himself, there’s one distinction Dr Ripoll made right at the start with regards to the two main types of dental photography:

1. Documentary
2. Creative

In brief, the difference between the two types is that documentary-style dental photography serves a clinical purpose whereas you can take more creative shots to express an artistic aspect of the oral cavity (teeth or soft tissues).

If you, like me follow lots of dentists on Instagram, I’m sure you’ve noticed that some dentists post more “beautiful”/artistic shots of teeth at cool angles with ‘sexy’ lighting whilst others post the ‘standard’ photographs of one of their patient’s teeth to showcase the significant transformations through “Before and Afters”.

Unfortunately, I cannot give you any examples here as I don’t want to use anyone’s images without their permission.

But if you’re curious to see a few examples of what I mean then why don’t you check out the following dentists Instagram accounts:

Artistic Dental Photography

• Dr Adamo Notarantonio
• Dr Carlos De Carvalho

Documentary-Style Dental Photography

• Dr Monik Vasant
• Dr Thomas Taha

Please Note – the four mentioned dentists above are just examples, there are so many super talented dentists who beautifully capture and document their work online that you can follow. They are just the first four names that came to my mind when writing this.

DOCUMENTARY-STYLE DENTAL PHOTOGRAPHS

There are some important factors we must consider to set the quality criteria for each image:

> FRAMING

This is very important. We must consider what is in frame when taking these kinds of images – it is so important for achieving reproducible images.

So for example, if you are taking a frontal shot in occlusion then bear in mind:

What teeth you can see on both sides (is it the same number of teeth? eg. to the first molars on left and right?

If you can get the framing of a photo correct at the time of taking your picture, this means that you are making the most of your camera and capturing all that you need to without having to do post-shoot editing on your computer to crop the images.

Another key advantage of getting your framing right is that it means if your camera setting remains consistent (as they should do always – especially for “before and after” shots) then you can be fairly confident that the lighting will always be consistent (that is the lighting coming from the flash). This is important because if you aren’t consistent it can cause differences in the pictures since light has different effects at different distances.

> TECHNICAL PARAMETERS 

Without getting to camera geeky here, what we mean by setting the parameters is the settings on your camera. If you have the right set up in your clinic and generally aim to use the same environment for all your pictures, then you can set your camera once and hardly have to change the settings.

Things to set will be: exposition, white balance (how cold or warm the images are), the depth of field (important to have a large field to avoid blurriness in your pictures) and set the sharpness.

There are settings you can change – for example by decreasing the aperture, you will increase the depth of field (meaning that using the example of a frontal occlusion image again: the posterior teeth will be in focus too)

> ARTEFACTS

It is important to avoid there being any artefacts in your images. When we talk about dental photography, the common artefacts that could be seen in your pictures would include the tongue, saliva, the mirror, retractors.

If you find that upon reviewing images taken, there are visible artefacts you might be able to crop the image slightly to remove these (eg. cropping the corners to remove cheek retractors), however there are some artefacts that cannot be cropped out (eg. saliva/bits of floss or cotton stuck between the teeth)

CREATIVE/ARTISTIC DENTAL PHOTOGRAPHS

Whilst there are ‘rules’ to aim to follow when taking documentary-style photographs, there are none** when you’re being creative! You can take whatever kind of pictures you want…

You have creative freedom 🙂

And I have seen some really cool ones on Instagram that serve no purpose clinically but are nice shots to appreciate

Some of the more random things you can take these kinds of pictures of are:

• The labial frenum
• A putty and wash impression of anterior crown preps
• Some water droplets on a tooth crown
• The saliva dribble running off a tooth
• The retraction cord around a tooth

Dr Ripoll gave his advice for anyone interested in experimenting with artistic shots. He said that in order to best capture the texture of the teeth and soft tissues, you need to use lateral light (as opposed to a light source coming directly from a flash attached to the camera) and this is so you have shadows!

**Contradiction Alert!!!

I know I just stated that are no ‘rules’ when it comes to this type of photography, Silvestre did mention that when carrying out a surgical procedure – if you want to spend time taking some artistic shots, take these before starting the surgery and then after completing the procedure. He gave this advice since it isn’t really appropriate to pause a surgery to mess around taking shots at all sorts of angles and making the patient wait with their mouth open with flaps hanging out. During a surgery, you can take photos but ideally, ask a trained assistant to take these images for you so that you as the treating dental surgeon can focus on the task at hand – and these images during the surgery would be for documenting purposes mainly.

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THE SET-UP

There are three essential components to consider for dental photography

1. The Camera
2. The Lens
3. The Lighting

Of these three, the most important is LIGHTING! Yep, I’m sure most of you would have guided the camera or the lens was most crucial, but we are wrong…

It is not the kind of flash used but the number of different kinds of light that can make a real difference to your photos.

THE CAMERA

The main difference between cameras is the sensor. You can have either a full frame or a cropped frame sensor. Generally, full-frame cameras are a lot more expensive!!

For those of you who may be into photography and have used old school camera setups, you will probably be aware of 35mm full frame sensors. The 35mm refers to the width of the film

Dr Ripoll said he personally prefers a cropped frame sensor. I can’t remember why – he did explain this…

Silvestre had a slide at this stage in the morning and it had a whole list of different DSLR cameras that are suitable for purpose – I cannot remember the full list because it was long! Essentially, most DSLRs including the entry-level models from Nikon and Canon were on the list (so you don’t have to take a second mortgage out to afford one!)

Fortunately for me, the DSLR I currently own was on his list of cameras that are fine to use for dental photography. But it is worth emphasising that you really need to have a DSLR – a compact digital just isn’t good enough since you cannot attach the right lens to them.

DSLR = Digital Single Lens Reflex 

THE LENS

There are two kinds of lens: fixed focal length and variable focal length.

So for example:

Variable -> 18-55mm / 28-200mm is the standard kit lens that you will get when you buy a DSLR

Fixed -> 35mm / 85mm / 105mm

It is important to use a fixed focal length lens for documentary-style photography to maintain consistency between images. So that each time you take images from the same patient (at different appointments) you are at the same distance away from them (as opposed to changing the focal length through a variable focal lens).

Many lenses have a VR button that can be switched on/off.

VR = Vibration Reduction

Dr Ripon’s advice is to switch off VR on the lens when using a flash. This is because vibrations are created by using the flash, thereby meaning the action of the VR in the lens is negated – so you might as well save some battery on your camera!!

VR is a great feature but is inappropriate for dental photography.

THE LIGHTING

As stated already, the lighting is the most important factor.

There are many different types of light that can be used/taken advantage of with photography:

• Ring Flash
• Twin Flash
• Studio Flash
• Hand Flash
• Soft Boxes

There is natural light or artificial light.

There is discontinuous light (eg. flash) or continuous light (e.g. softbox)

So many of the settings you can change on your camera are changing the effects of the environment’s light:

• The White Balance depends on the flash
• A higher ISO increases the sensor’s sensitivity to light (at the expense of grainy images)
• A faster shutter speed means less light comes through
• A wider aperture means more light comes through

Another difference is Hard Light or Soft Light. Hard light gives more shadows than soft light which gives less/no shadows.

One kind of light is not better/worse than another – they just behave differently and so are appropriate/ideal in different situations. It all depends on what kind of photographs you want to take – sometimes the only way to know is to experiment!

Different kinds of light are more or less appropriate in certain settings; for example, if you’re taking a portrait headshot for a new passport then it would be best to have soft light so your beautiful face is well lit with no shadows.

To give a non-dental example:

As an amateur photographer, I am beginning to gain a greater appreciation for natural lighting. Things, spaces, areas can look so different at different times of day/different seasons due to the sun’s light. On a clear day, there’s an amazing time period just before sunrise and just around sunset when there’s a perfect glow – beautiful warm soft light – it’s called Golden Hour and is a great time of day for photography!!

What Influences the light’s quality?

The type of light depends on two main factors:

1. Relative size of the light source
2. Distance of light source from subject

The bigger the light, the softer the light. The bigger the light, the less shadows

The greater the distance the light source from the subject means that the light is relatively smaller with respect to the subject – i.e. the harder the light

SOFT LIGHT = big light source, close to the subject

HARD LIGHT = small light source, far away from subject

The sun, for example, is a source of hard light when shining brightly in the sky – it makes shadows! But then let’s say its a cloudy day, the light from the sun is diffused thereby changing it to be a soft light source from the sky.

Dr Ripoll said he likes to uses bouncers attached to his twin flash system. And he takes this a step further to provide well balanced soft light when taking dental photographs by folding a piece of paper around the bouncers (an ingenious cheap way to modify your light source). He recommends the Lumiquest bouncers.

Silvestre said to us all that we should never use brackets and a diffuser (bouncers with paper) since the two components contradict each other’s purpose! Because by using a bracket to extend the twin flashes (i.e. make them further away from the subject)  you make the light harder) and by using bouncers you are trying to soften the light. Forget the brackets, not needed!

DON’T BE CHEEKY!!

Dr Ripoll called out some dentists who manipulate the light in their dental photography to enhance the “after” images for “before and after” for teeth whitening cases.

• In the before photos, they use more lateral light
• In the after photos, they use more direct frontal light

The difference makes the after images brighter so the whitening result is artificially emphasised by the level of light used making their transformations bigger.

This is a classic example of what I mean. Doctor Michael Apa is an internationally renowned dentist working between Dubai and New York City; he is prominent on social media and has a large following (for a dentist). He is an inspirational figure in the international dental community, and rightly so, he produces excellent results for his patients, is incredibly driven, business-minded and charismatic. His approach to cosmetic dentistry is somewhat questionable to me (my own opinion) in that he seems to basically just puts porcelain veneers on everything and charges extortionate amounts for the service, but it is disappointing for someone like him to try and fool people by using these cheeky little tricks…

Still on the topic of lighting, lets briefly discuss the two different types of flash that are used most commonly for dental photography.

RING FLASH is:

• Artificial light
• Hard light
• Discontinuous
• Frontal

The Advantages of Ring Flash:

• Smooth and Homogenous Illumination
• Modelling Light (focus aid)
• Comfortable, lightweight, quick to use

The Disadvantages of Ring Flash:

• Unusual unaesthetic circular reflections
• Flat Lighting
• Impossible to use diffusers

TWIN FLASH is:

• Hard or Soft light
• Artificial light
• Discontinuous
• Frontal/Lateral light

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PORTRAIT PHOTOGRAPHY

Portrait photographs are extra-oral. These are still very important and taken often in a dental setting.

They are great for capturing a patient smiling, their profile and facial shape/structure.

When taking portraits, Dr Ripoll’s advice is to only use one softbox light with the reason being that if two softboxes are used to light up the subject, they will have two white circles/squares in their eye’s reflection. So to make the pictures seem more natural, use only one softbox and this gives a nicely lit subject with a little shadow for effect.

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ADDITIONAL ACCESSORIES

There are a few other important accessories a dentist must own, the most common are:

• Lip & Cheek Retractors
• Contrastors
• Mirrors

There are different shaped mirror that can be used depending on the image being taken and the size of the patient’s mouth opening. A good tip to stop the mirror fogging up front the patient’s breath is to warm the mirror slightly before use.

Lip & Cheek retractors can be either black or transparent. If used properly, either is fine as they will be out of shot mostly (but perhaps consider the transparent version ideally).

Dr Ripoll recommends using Metal contractors as opposed to Silicone contractors. Both are black but by using a metal version, it allows you to achieve reflections which can sometimes give a nice effect to the images. So I think it would be a good idea to own at least one of each to give you more flexibility with your photography.

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Dr Ripoll made some comparisons that I thought were great so wanted to share them with you all too:

He compared a camera lens to the human eye.

• The pupils constrict or dilate dependent on the light levels.
• In a very bright room or if you look directly into the sun for example, your pupils will constrict to have very narrow openings as there is so much light they don’t want loads and loads to get in.
• If you are walking in a big field at night, with the only light coming from the moon and a few stars in the sky then your pupils will be dilated to allow as much light in as possible.
• On a camera, we can control the diaphragm to be more or less open to let more or less light through. We do this by changing the ISO setting. The lower the ISO, the smaller the diaphragm opening. But we make a compromise by increasing the ISO to make the sensor more light sensitive since this will, unfortunately, cause the image to become grainy.

He compared shutter speed to a water tap in a bath. 

If you open the tap more (turning it more to the left) then more water will flood out (i.e. water flows out faster). If you only slightly open the tap, water will still come out but at a lesser flow rate. So in order to fill up a bath to a desired level, you can either open the tap fully for a shorter period of time, or open the tap just half way and let it flow for a longer period of time.

This, in essence, is the same principle for shutter speed. The longer the shutter on a camera stays open, the more light comes through. The faster the shutter closed, the lesser the light that comes through to the sensor.

In general photography, by altering the shutter speed we can make some really nice looking photos by manipulating the exposure.

We can balance settings against each other by making allowances. This is known as Exposition Compensation. We can change the:

• Flash
• Shutter Speed
• Aperture

Both above changes will result in the same level of light, the only thing that changes is the depth of field.

Things can begin to get unnecessarily complicated (especially if like me, you are a relative beginner when it comes to photography) when we consider the flash settings for your external flash device (ring/twin). Because when adjusting the settings on your camera for light, you have to always bear in mind that once you press the shutter button to take a photo, the flash will go off providing additional light to the subject.

Apparently, on the flash, you can manually set the flash speed (i.e. how quickly after you press down on the shutter does the flash go off). Dr Ripoll suggested we keep things simple and in all situations, if you set the Flash Sync Speed to be either 1/200 or 1/125 you will get a good result.

DEPTH OF FIELD

The depth of field refers to how much of the image is in focus. If you think about it, in any setting, there are objects at different distances from the camera/human eye.

So lets say you put your hand out in front of you and look at it, you will find that everything else in the background will be blurry since you are focussing on your hand and nothing else in your field of vision at that moment in time.

When we consider this in terms of camera settings – it is known as the F-Stop. The smaller the diaphragm opening (i.e. the higher the F-Stop), the sharper the image. The lower the F-Stop, the greater the diaphragm opening meaning that more of the background will be out of focus.

In dentistry, we want all the teeth to be in focus, so ideally we want to set a higher F-Stop value before taking the picture.

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DR SILVESTRE RIPOLL’S SUGGESTED SETTINGS FOR INTRA-ORAL PHOTOGRAPHS

F-Stop = 22-32

Shutter Speed = 1/125ths of a second

ISO = 100

If you are a dentist taking photographs of patients all the time, then it is definitely a good idea to keep a specific camera in your clinic to use. So if like me photography is also a personal hobby, then you should make a decision at some stage in your career to invest in a second camera. This way you keep one in the clinic, and one at home.

This idea of having a specific camera to use for your dental photography also means you less hassle for you when it comes to resetting the camera every time; if it stays in the dental surgery, it will always keep the same settings making your life a little easier and improving your workflow!

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WHITE BALANCE

White Balance can seem like a complicated bit of dorky camera jargon, but it is really quite a simple concept.

DSLR cameras are able to adjust the white balance for an image dependent on the light.

Your camera can adjust the WB to make the image warmer or colder because the light will affect the colours in your photograph. These adjustments made are aimed at compensating for the effects the light has on your image.

If you think about it, the light really does change things. Think about the different kinds of light you can have: direct sunlight, cloudy sunlight, fluorescent light, incandescent light, light from a flash etc.

Dr Ripoll said that with dental photography, we can simply use the Auto-WB setting, or the “Flash” preset or if you want to manually set the WB, set it to 5500.

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METERING MODE

Dr Ripoll also briefly discussed metering and the metering mode settings on DSLR cameras. I have decided not to write about this here since to be perfectly honest with you – I don’t quite understand it all yet myself!!

Every modern DSLR has something called “Metering Mode”, also known as “Camera Metering”, “Exposure Metering” or simply “Metering”.

Knowing how metering works and what each of the metering modes does is important in photography, because it helps photographers control their exposure with minimum effort and take better pictures in unusual lighting situations.

Metering is how your camera determines what the correct shutter speed and aperture should be, depending on the amount of light that goes into the camera and the sensitivity of the sensor.

The most common metering modes in digital cameras today are:

1. Matrix Metering (Nikon), also known as Evaluative Metering (Canon)
2. Center-weighted Metering
3. Spot Metering

These are important on TTL mode for flashes.

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RAW v.s. JPEG

This is a controversial debate amongst photographers across the world. 

It is of particular debate with regards to dental photography but Dr Ripoll seem’s fairly stubborn in his viewpoint which is that there is no need to use RAW image files.

Silvestre uses JPEG for all his images. 

He argues that RAW is a file type, it is not a picture! RAW is a negative, it must be processed to be viewed.

JPEG is a method of compression. JPEG is a universal image format.

Furthermore, RAW files are very large, taking up huge amounts of space on a memory card.

The argument that champions the use of RAW files for dental photography is one that suggests a RAW file can be proven to be undoctored whilst if a dentist sends you a JPEG image of a patient of theirs, who is to say that they didn’t alter the images on photo editing software???

For example, I can change the shapes of the teeth, make the gums pinker, make the teeth whiter, smooth out any rough margins on Photoshop or LightRoom to make the images look better. Then save the image file as a JPEG…

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SUMMARY OF SETTINGS

CAMERA

• Closed Diaphragm = f/ 22 to 32
• Shutter speed =  1/125
• ISO Native = ISO 100
• WB = Flash preset or Auto
• Metering = Centre Weighted (only in TTL)
• Focus Mode = Punctual
• Colourspace = sRGB
• Picture Style = Normal

LENS

• Vibration Reduction = OFF
• Focus Mode 
  • Manual = Greatest Magnification
  • Auto = Other Situations
• Full Focus

LIGHT SOURCE

• Manual = Change F-Stop and Flash Power
• TTL = Exposition Compensation

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So that is most of what we learnt on the day! It was very informative and easy to follow.

It was a long day but a great day if you’re as dorky as me. Especially for you students reading this!!

Dr Silvestre delivered his presentation in the morning and then in the afternoon it was all just a live demonstration. Dr Ripoll called upon one willing volunteer from the audience to offer their oral cavity up as a model for the day, and he took multiple pictures showcasing tricks for producing amazing photographs.

This afternoon was really interesting to watch and definitely complimented the morning talk well. Putting into practice what we had all been taught; it’s one thing to be told something but seeing it applied practically helps to assimilate the newly acquired information.

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The more and more I learn about dental photography, the more confident I am becoming with it all. So in a few years time when I qualify as a dentist and am working as a vocational trainee, I will be ready to start capturing some great shots from my patients. And before that of course, whilst at dental school we do learn a little about macro photography and can loan out a DSLR with the macro lens and a ring flash to take photos of our finals cases.

Who knows, I might even consider setting up a photography ‘masterclass’ workshop in the dental school and lead it myself?! I could collaborate with the Dental Institute and the Photography Society to set up a workshop where I could try to teach the basic principles to other students 🙂

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Another reason why it was such a worthwhile day (from a broke student’s point of view) is that I was well fed throughout the day! There was a mid-morning break for tea/coffee, biscuits and other little snacks. Then at lunch we had 45 minutes with a buffet of food set out. Also again, half-way through the afternoon we had a break for tea/coffee and snacks. All of this food and drink was complimentary meaning that all I had to do was pay £1 to book my place and a train ticker from London to Bracknell!

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Thank you to the BACD for hosting the event – it was great. More free events, please!!

I hope any young dentists/students reading this found it somewhat useful. When writing this post, I used the notes I made on the day but bear in mind I didn’t write down everything so in fact, I learnt a lot more myself by being present.

I’d highly recommend any UK based dental students to sign up as members to the BACD. You don’t necessarily need to be hugely interested in cosmetic dentistry to be a member in my opinion but at least have an appreciation for the aesthetic dentistry and artistry involved. Aesthetic dentistry isn’t a speciality in itself, in fact, you can consider many kinds of dentistry to be aesthetic if done properly with finesse by highly skilled dentists! As long as we strive for clinical excellence in any area of dentistry you can perceive it as aesthetic (subjective!!!). For example, someone might look at an RCT radiograph and say it’s done beautifully!! 🙂

Thanks for reading.