Clinical Photography Knowledge and Skills among Dental Students in Saudi Arabia: A Cross-sectional Survey.

BACKGROUND AND AIM: Clinical photographs have become an important entity in contemporary dental education in Saudi Arabia. The study assessed the knowledge and skills related to clinical photography among final-year undergraduate dental students in different dental schools in the Western province of Saudi Arabia.
MATERIALS AND METHODS: A face-to-face interview was conducted using a pretested and validated questionnaire after obtaining relevant consent from the college administration and the students. Trained and calibrated data collectors interviewed the dental students between November 2019 and February 2020.
RESULTS: The knowledge related to clinical photography was "good" only in 17.2% of the participants, and most of the students demonstrated "poor" knowledge (58.9%). Digital single lens-reflex (DSLR) camera was used by only 43.9% of the students for taking clinical photographs. The practice of taking informed consent from patients for taking and using clinical photographs was reported in 77.6% of the dental students.
CONCLUSION: The knowledge related to dental clinical photography was not satisfactory, and students need to improve the understanding of the proper functioning of digital cameras and also the medicolegal issues related to clinical photography. Copyright:

INTRODUCTION

Dental education has undergone a drastic transformation from the past and has evolved more to a digital era. The growth of technologic capabilities has significantly helped in improving the clinical effectiveness of dental care offered. Developments in digital photography have helped dentists to enhance their practice management skills efficiently. Data show that the use of clinical photography by dentists has increased over the past decade, and dental photographs have become inevitable documents in current dental practice.[1]

In dental schools, clinical students utilize this digital photography for case discussion, presentation, and patient education and motivation. Digital dental images (DMIs) enable dental students to record key stages of treatment and could also be used as supportive documents in case of medicolegal problems, thus protecting the rights of patients and students or dentists.[2] Knowledge related to basic principles of photography, devices, accessories, their settings, setups, and documentation is essentialities to capture high-quality clinical photographs.[34]

In Saudi Arabia, the dental curriculum allows the students to record and store patient's clinical photographs as a part of comprehensive clinical case management.[5] There is a lack of studies done to understand the knowledge, attitude, and practices related to digital clinical photography among dental students. These types of skills could be considered as a hidden curriculum in the current dental education system that is rarely assessed. No studies are done in the Kingdom regarding the knowledge, attitude, and practices regarding the. Thus, the current study aims to explore the level of knowledge, attitudes, practices, and perceptions of clinical photography among students and interns of dental schools in the Kingdom.

MATERIALS AND METHODS

A cross-sectional study was conducted among students pursuing their degrees in the Western Province of Saudi Arabia, including three main cities Jeddah, Makkah, and Taif. A pretested and validated questionnaire to collect information from undergraduate dental students (final year and internship) from November 2019 to February 2020. The investigators will identify participants based on the inclusion and exclusion criteria. Students who have not performed any clinical photography and who did not consent to participate will be excluded from assessing knowledge, practices, and experiences after the eligibility check.

Face-to-face interview using the validated questionnaire was carried out using calibrated and trained data collectors. The questionnaire consisted of closed-ended questions covering the items that measure knowledge, attitude, practices, and perception regarding clinical photography skills. The validation and standardization of the questionnaire items and a standardized methodology were followed to validate this questionnaire that included focus group discussion, expert evaluation, pilot study, reliability, and validity assessment, etc. Items with correlation coefficient >0.7 were removed. In the reliability check, internal consistency was done, but test/retest reliability could not be performed because of time scarcity. A Cronbach's α value >0.7 was considered for the questionnaire to be internally consistent.

A minimum sample of 276 was calculated considering the values derived from the pilot study using the software nMaster 2.0 (CMC, Vellore, India). A mixture of convenience and snowball sampling was followed, considering all the colleges in the three cities in the Western province. Data collectors briefed the participants about the study purpose and benefits. All the participants were ensured confidentiality of the information they have provided. The Research and Ethical Committee of the institution approved the study, and consent to interview the students was taken from the colleges' concerned dean where participants were pursuing their degree.

All the data obtained through the questionnaire were tabulated accordingly using MS Excel software. The data analysis was done using SPSS Version 23 (IBM Corp. USA). Frequencies and percentages were used to summarize descriptive data. Pearson's Chi-square test and/or Fisher's exact test were used to see the possible association between categorical variables. A significance value (α), P < 0.05 was considered statistically significant.

RESULTS

This study assessed the basic knowledge about the properties of photography, their application, experiences, and attitudes toward dental clinical photography in their academic settings. Our study included 406 dental undergraduates students from 5th year (31.8%) and 6th year/internship (68.2%) studying in different dental schools in the Kingdom of Saudi Arabia. There were 11 knowledge items in the questionnaire that covered different “must know” properties/features of clinical photography. Each correct responses were given a score “1” and wrong answers were given score “0;” thus, the maximum score 1 could get was 11. The mean total knowledge score in our study was found to be 4.53 ± 3.06. The total scores were then converted into percentages, which were then categorized into “good” (>75%), fair (50%–75%), and poor (<50%). The analysis showed that 17.2% had “good,” 23.9% “fair,” and 58.9% “poor” knowledge regarding clinical photography.

When the relationship of this knowledge with the participants' gender, it was found male students have shown comparatively more “good” knowledge (34.5%) than female students (10.6%), and poor knowledge was found significantly higher among females (63.1%) than male students (47.8%) that was statistically significant (P < 0.001). The sixth year/internship students had comparatively more “good” knowledge scores (17.7%) than 5th-year students (16.3%), whereas poor scores were found in 5th-year students (70.5%) than 6th-year students (53.4%), both of these associations were statistically significant (P = 0.001). There were no statistically significant differences seen in knowledge between private and government dental school students [Table 1]. The knowledge related to various photographic properties and functions is depicted in Figure 1.

Table 1

Knowledge about photography and its relationship with student characteristics

	Knowledge			Total	P*
	Good	Fair	Poor
Gender, n (%)
Male	39 (34.5)	20 (17.7)	54 (47.8)	113 (27.8)	<0.001
Female	31 (10.6)	77 (26.3)	185 (63.1)	293 (72.2)
Year, n (%)
5	21 (16.3)	17 (13.2)	91 (70.5)	129 (31.8)	0.001
6/internship	49 (17.7)	80 (28.9)	148 (53.4)	277 (68.2)
College sector, n (%)
Private	34 (14.6)	54 (23.2)	145 (62.2)	233 (57.4)	0.183
Government	36 (20.8)	43 (24.9)	94 (54.3)	173 (42.6)

*, p<0.05 is considered statistically significant

Figure 1

Knowledge related to different parameters of camera

When the practices related to clinical photography were explored, it was found that 74.6% (n = 303) of our study population used a camera for capturing a clinical image. Hence, we used only these students' responses (n = 303) for assessing the practices related to clinical photography. The most common type of device used to capture clinical images was the Digital Single Lens camera (DSLR) (43.9%) followed by smart phones' camera (40.6%), fixed zoom lens camera (13.5%) and point-shoot camera (2%). It was observed that 57.4% of them always used a flash while capturing clinical images [Table 2] and “Ring or Micro” flash was the commonly used one (38%), whereas 10.4% used built-in flash of the camera. It was reported by the participants that 61.4% and 61.2% of students always used a cheek/lip retractors when taking a frontal view clinical photographs and used occlusal-buccal mirrors when taking a quadrant/arch occlusal photographs, respectively. Participants who always took consent from the patients before capturing dental images were 77.6% and 60.5% of them reported that they faced some kind of objections from the patients while taking consent [Table 2].

Table 2

Practices related to clinical photography

	n (%)
Used a camera for clinical photography (n=406)
No	103 (25.4)
Yes	303 (74.6)
Type of camera for capturing a dental clinical image (n=303)
DSLR	133 (43.9)
Fixed zoom lens camera	41 (13.5)
Point-shoot camera	6 (2.0)
Smart phone’s camera	123 (40.6)
Type of lens used for clinical photography (DSLR only) (n=133)
Macro lens (50-180) (mm)	61 (45.9)
Standard lens (35-85) (mm)	30 (22.6)
Other type	6 (4.5)
I don’t know	36 (27.1)
Commonly used flash for clinical photography (n=303)
Always use flash	174 (57.4)
It depends on the amount of light	95 (31.4)
Don’t use flash at all	34 (11.2)
Use a cheek and lip retractors when taking a frontal view clinical photograph (n=303)
Always use these retractors	186 (61.4)
Use depending on the needs	96 (31.7)
Don’t use, as they are expensive	21 (6.9)
Use of occlusal-buccal mirrors when taking a quadrant/arch occlusal photograph (n=303)
Always use occlusal- buccal mirrors	185 (61.1)
Use those depending on the needs	76 (25.1)
Don’t use those, as they are expensive	28 (9.2)
Don’t use those, as they are uncomfortable	14 (4.6)
Take consent from the patient before capturing clinical photographs (n=303)
Always	235 (77.6)
Sometimes	40 (13.2)
Never	28 (9.2)
Objections from patient for taking clinical photography (n=303)
Always	41 (13.5)
Sometimes	143 (47.2)
Never	119 (39.3)

DSLR: Digital single lens camera

The experiences and perceptions related to clinical dental photography are illustrated in Table 3. It was reported that 41.1% (n = 167) of the participants attended course/workshops/CDE on clinical photography and 15.6% (n = 26) of them found it was very effective. When 54.4% (n = 221) reported that their academic setting provided course/workshop/CDE, 73.2% had the opinion of including clinical photography in the dental syllabus [Table 3].

Table 3

Experience and perceptions on clinical dental photography

	n (%)
Experienced enhancement of clinical effectiveness with clinical photograph
Always	146 (36.0)
Never	35 (8.6)
Sometimes	225 (55.4)
Plan to continue using clinical photographs in your future practice in the same way
Always	212 (52.2)
Never	7 (1.7)
Sometimes	111 (27.3)
Not planned yet	76 (18.7)
Attended course/workshops/CDE on clinical photography
No	239 (58.9)
Yes	167 (41.1)
Outcome of the attended course/workshops/CDE on clinical photography (n=167)
Very effective	26 (15.6)
Effective	63 (37.7)
I don’t know	70 (41.9)
Not effective	8 (4.8)
Academic provide (d) course/workshop/CDE
Yes	221 (54.4)
No	116 (28.6)
I don’t know	69 (17.0)
Suggest including a course/workshop/CDE in your syllabus
Yes	297 (73.2)
No	48 (11.8)
I don’t know	61 (15.0)
Number of course/workshops/CDE on clinical photography attended
One	83 (20.4)
More than one	98 (24.1)
I don’t remember	20 (4.9)
Didn’t attend any	205 (50.5)

CDE: Continued dental education

DISCUSSION

The findings of this study showed that the knowledge related to clinical photography was not satisfactory among the students. Clinical photographs have become one of the essential documents in the dental curriculum, and clinical students need to be acquainted with the properties, techniques, and equipment used for it. The clinical uses of photography for dental students include treatment planning, documentation of the treatment, follow-up, self-evaluation, and referrals to specialists or tutors for a case discussion.[6] The male students had better knowledge regarding dental photography compared to female students. This gender difference could be explained by the fact that male students usually exhibit more interest and engagement in technological activities compared to females, thus further increasing their knowledge and skills in photography.[78] Furthermore, students in the final year showed better knowledge scores than 5th-year students. The reason for this could be attributed to the formers' experience and acquaintance with clinical photography during the previous year of training.

It was reported that, among students who took clinical photographs, only 43.9% used Digital single-lens camera (DSLR), and the rest used other types of cameras including smartphone cameras. A DSLR camera is favored for clinical photography because of its wide range of options to change parameters such as exposure (ISO sensitivity), aperture, shutter speed, and also the ease of use compared to the conventional ones.[9] The study showed that the knowledge related to parameters such as exposure, aperture, shutter speed, and image stabilization was poor among the students. It was found that the macro-lens (focal length of 50 mm− 1 80 mm) was used by 46% of the students who used the DSLR camera. One of the advantages of using a macro lens in dental photography is its ability to focus closely on small objects that will give you sharp images with less distortion and better color accuracy, which is very much imperative in the documentation process.[31011]

Most digital cameras come up with an in-built flash, and DSLR cameras usually have it in a “pop-up” style. Sometimes, the in-built flash may not sufficient to give the required light in clinical setups, which necessitates an additional flash for improving the lighting of the objects.[12] When capturing intraoral clinical images, it is advisable to use cheek and/or lip retractors (frontal view) and mirrors (quadrant/arch occlusal view) for improved visibility.[1314] It was found that the majority of the participants always used these retractors in their practice. Another challenging aspect of clinical photography is patients' consent and confidentiality. Approximately 78% of the participants took consent from patients before taking clinical images. Dental images are used for various purposes, and there is a need to preserve the anonymity of the patient data and must be securely archived. It is the students' responsibility to take informed consent and ensure confidentiality of the images being captured.[1516] According to the data protection Act, “Patients have a fundamental legal and ethical right to determine what happens to their bodies.”[17] The unconsented use of clinical photographs may cause a loss of morality and privacy in patients. In this study, most students suggested to include a course or workshop about clinical photography in their syllabus. The findings showed that very few students attended more than one course/workshop/CDE in clinical photography. Dental colleges should impart some hands-on courses, CDE programs, and workshops on clinical photography and seriously think about the need to include some topics related to this curriculum. The study findings give us a picture that there is a need to improve the understanding of various essential aspects of digital photography among dental students, and knowledge regarding common mistakes could minimize the errors in photography, thereby achieving better clinical images. One of the study's strengths of this study is that we used a face-to face interview method to collect the response, which could have minimized the response and social desirability bias, as there were no provisions given to refer or ask the questions to someone that enabled to provide actual knowledge. The closed-ended items in the questionnaire could have increased the accuracy and inter- and intra-rater reliability in data collection.

CONCLUSION

Even though dental students used digital photography for clinical purposes, the knowledge related to the essential and fundamental properties was not that satisfactory. The findings could help the dental faculty to assess the current skills or competencies of digital photography among students and thus plan an additional course(s), workshops, CDE programs for knowledge, and skill enhancement in clinical photography.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.