Glued to the screen - just like the telly

Sept. 1, 1996
The intraoral camera is unquestionably an ideal tool for making patients understand dental problems. So don`t let it collect dust just because you don`t know how to use it.

The intraoral camera is unquestionably an ideal tool for making patients understand dental problems. So don`t let it collect dust just because you don`t know how to use it.

Cheryl Farr

Many hygienists are still struggling with the learning curve in intraoral cameras, which can be steeper than it looks. Without proper understanding of the tool, the result can be frustration and discouragement. Lack of skill with the technology or misinformation about implementation leads to wasted time and confusion over when, where, and how, as well as with what patients to use the technology. The worst case scenario occurs when this very expensive and powerful tool is relegated to a dusty closet or unused corner of the practice - a scenario occurring in more than a few practices as I have discovered through my lecturing and consulting.

What accelerates some hygienists up the slope of the steep learning curve is the reward at the top. According to hygienists who have mastered their use, intraoral cameras open up a whole new universe of possibilities in hygiene. Hygienists find IOC technology produces an astonishing change in patient behavior. Previously skeptical, hesitant, and even resistant patients become involved with their treatment, assist in diagnosis, and are eager to have their problems resolved.

Kristen Crawford, RDH, often lectures on intraoral technology. She explains one key reason for their impact. "When a patient sees the inside of their mouth for the first time on a TV screen, highly magnified, the shock is enormous. The average patient wants to have a healthy mouth, but it is clear from the images on the camera that their mouth is not healthy. I`ve found that I often don`t have to say a word. The image is enough to make a believer out of them."

Intraoral cameras are actually miniaturized video cameras, originally developed for "spying" purposes. In 1988, handpieces were designed that adapted the cameras to the special needs of examining the oral cavity, and intraoral cameras (IOCs) were born. The first IOCs were greeted with curiosity and confusion by the dental profession. They quickly caught on, however, and in the past few years more than 35,000 IOCs have been sold. More than half of these cameras are now in hygiene operatories and being used by hygienists.

Initially, all IOCs were stand-alone systems that were wheeled around on carts. Today, the most common system sold is a multioperatory system. In these systems, the camera is a portable unit and is carried from room to room. Monitors for viewing intraoral images are placed in every operatory. The video printer, along with the still video recorder and sometimes a CD player, are consolidated at a media station centrally located in the practice.

The most advanced form of IOC technology is a computerized system where the intraoral images can appear on computer monitors. The system is almost always integrated with practice management software, clinical charting packages, and sometimes even computerized X-rays. On these systems, all information can be entered and viewed chairside, eliminating the need for patient charts.

Down-to-earth guidelines for the use of IOCs in hygiene are difficult to locate. Since the technology is so new, there is little formalized training available in hygiene schools or courses, and vendor training tends to concentrate on hype, flash, and special features rather than practical implementation methods.

Currently, most hygienists are self-taught on the technology. This trend leads to both highly creative solutions and to "blind spots" on the basics, because of few opportunities for shared experiences. Since these tools are so powerful, knowing how to make the best use of them is important. Some nuts and bolts principles can be highly useful to hygienists that are interested in expanding their abilities through the use of IOCs.

Features and components

If the hygienist is involved in the IOC selection, the emphasis should be placed on ease of use. Many dentists focus too much on image quality when evaluating the technology. Most cameras actually differ little in image quality, and these differences seldom have any impact on success with the technology. On the other hand, cameras are often abandoned or seldom used after purchase because the handpieces are too heavy, poorly balanced, or too difficult to focus.

The best camera handpieces are lightweight and functionally designed to allow easy access to controls. The camera should taper, but only slightly. When the part you are holding is much heavier or bigger than the viewing end, it is much harder to maneuver accurately, which is one of the reasons the gun-style handpiece design is less than optimal for extensive use.

What do high-tech nerds suggest about using IOCs

- If the technology is new to you, develop your skills before attempting to implement it during patient exams. The pathway to successful implementation of IOCs begins with developing the necessary manual skills. Since IOCs can magnify tooth structures 25 to 30 times, precise control is essential. In a few minutes of trial and error, you can acquaint yourself with how to use the various lighting controls, how to switch lens, and so forth.

But this quick knowledge will not help you with your most difficult task, which is to keep it in focus both during video "tours" and when attempting to capture images. Through repeated attempts, most hygienists have found that focusing is easier when they stabilize the handpiece on the opposing arch. During buccal or lingual shots, use your other hand as a fulcrum.

Ninety percent of the use of IOCs in hygiene is for single-tooth shots, so when you can freeze or capture these images easily, you are ready to use it with patients.

- Train yourself to perform the IOC exam with the patient sitting up instead of reclining. Place yourself behind them. In that position, both you and the patient will have a clear view of the monitor, and you will experience less back strain.

If you have a choice on the type of control for capturing shots, select the foot control. Despite having too many rheostats on the floor already in hygiene, most hygienists end up preferring a foot switch, because it lessens the likelihood the image will be out of focus.

Some cameras have a switch on the handpiece, which is either an excellent solution or the worst case scenario. In some cases, it is difficult to push the button without moving the whole camera slightly, which puts the image maddeningly out of focus. If the camera only comes with a remote control, put a piece of Velcro over the freeze button. Remote controls have to be activated by the patient, and the patient will automatically dip their head to look at the remote control when they are asked to push the button. When that happens, the image is out of focus once again.

Leading-edge cameras respond to spoken commands so the operator can use voice input for capturing and recording images. Voice input is the best method of control, but it requires computerization and expensive voice technology.

- Prepare the patient before the exam by briefly explaining what the camera is and why you use it. Use a simple statement such as, "This is a new piece of equipment that allows us to put your teeth and gums on television. How does that sound?" If the patient seems hesitant, focus the camera first on some other object than their teeth and capture an image on the monitor to show them. The patient will relax as they understand how the camera is used.

Many hygienists also have found it useful to have an interesting image on screen in the operatory that an entering patient sees immediately. "The whole staff has had cosmetic dentistry, and we put their before and after smiles on the screen in split-screen formats," said a hygienist in New York. "We`ve found that it automatically opens up the conversation."

- If cosmetic dentistry possibilities are going to be reviewed, use the extraoral lens first and capture four images for a baseline. Capture four images: full face, smile, upper and lower arch. Use these images to focus on cosmetic dentistry possibilities and find out patient`s areas of interest before the exam.

It seems to be a general rule in the industry that IOC systems either do a good job with intraoral images or extraoral images, but seldom both. Therefore, you will probably have to decide which is most important to your practice when selecting the camera. In a practice that provides extensive cosmetic dentistry, the extraoral lens will often be the most important component of the technology, especially if the captured images are going to be manipulated to create before and after images of patients.

- Do a complete video exam with new patients. The sequence of the full-mouth exam should always be the same. This eliminates confusion when the exam is reviewed later. Most hygienists start with the distal of the maxillary right, work around the arch, switch to the mandibular left and then go over to end at the right, but any pattern is acceptable as long as it is consistent. As you become more dexterous, you may find it helpful to use an explorer to point to different things during this phase of the IOC exam.

- During the video tour, concentrate on ways to educate about periodontal disease. Explaining about periodontal disease is one of the most important tasks in hygiene, but it also adds much stress to the day`s work. Even the most skillful and comprehensive explanations will be met by a patient`s blank stare. IOCs can relieve that stress. Learn to say, "here let me show you," instead of launching into a lengthy verbal explanation. Put an image on screen and bite your tongue. In many cases, you won`t have to say anything. The visual image will be enough.

When you have a patient who thinks passing a brush over their teeth is adequate home care, for example, put the camera down on the lingual of their lower anteriors where the calculus collects. Don`t say a word. Take a curette and chunk off a big piece of tartar. The sequelae of poor or effective home care can be made quite graphic to a patient, making the educational process easier.

IOCs also make periodontal disease indicators and progression immediately understandable to patients. Given all the time constraints and demands in the profession, the challenge of getting a patient to understand what a "5 millimeter" pocket is or why they need full-mouth probing is almost unimaginably difficult. In most cases, patients don`t even have a clear idea what a periodontal pocket is. They just think the hygienist is "poking around in their gums."

Instead of trying to explain what a pocket is, put a probe into a deep pocket while the patient watches during the video tour. When the patients see what appears to be an extraordinarily long length of a highly magnified probe disappear into a pocket right next to a tooth, they are shocked. You can add more drama by squeezing pus or blood out of the pocket. The technical challenges of your job is suddenly clear to them. They will be more appreciative and more likely to take ownership of their disease.

- During the video tour, capture images for the doctor to discuss later, arranging them in a split-screen (four-plex) format. To keep the schedule under control and limit the time spent, try to capture no more than four images. Many times, hygienists capture far too many images. It is not necessary to show every fracture line, broken cusp, or broken-down restoration. Nor is it always necessary to take the time to explain the images to the patient.

Crawford points out, "I usually deliberately don`t explain the images. The patient is staring at the screen the whole time I am completing the cleaning. By the time I am done, they are really anxious about what can be done, which is a great entry for the doctor." When the dentist enters to assess findings, the images on the screen provide excellent non-verbal guidance.

- Be discretionary in the use of the camera with recall patients. If an hour is scheduled for every hygiene appointment, a complete video tour is possible. But during a more typical hygiene appointment schedule, a complete tour can simply take too much time.

Crawford says, "When seeing a recall patient, you will probably want to look at their chart and limit the exam to the areas of concern. Only spend a few minutes with the camera on these patients." During that time, show them areas of concern, or reinforce education on periodontal disease. Another excellent alternative is to showcase restorative work that was completed in their last appointment, as a validation for the quality of the work done in the practice.

- Experiment with the camera to discover new ways to save time and increase your own productivity. Some hygienists capture images before and after the hygiene appointment, motivating the patient to better home care when the difference is noted.

As patients begin to understand the appearance of healthy and unhealthy tooth structure, they will become involved in their own diagnosis. They will begin to look more closely at their teeth at home, noticing gum problems and the buildup of stains and plaque. With a recall patient, if a patient is resisting treatment, print an image of the tooth being "watched" and put it in the patient`s file. When they return for their next appointment, show it to them as documentation of continuing deterioration.