Poor documentation of dental cases will result in inconsistent and unsupported treatment. Each dentist and dental practice must ensure that patients’ records are all complete not only in terms of demographics, identification and medical history but also in terms of missed appointments, dental fear or anxiety. The American Dental Society (ADA) releases Current Dental Terminology (CDT) biannually which describes claims processing through insurance companies and how dental offices can comply with these standards. Dental documentation is an essential part of this process and dental clinics have must commit with the guidelines of archiving patients’ data.

The traditional ways for keeping patients’ records were written charts, X-rays and molds. However, with the advances in technology, now it became easier to document dental cases through electronic health records (e-health records), 3D digital impressions and dental photography. Patients’ records can now be stored in electronic folders named with patients’ names, containing 3D images, health records, questionnaires, electronic radiographic/scanning images (taken by sensors and electronic X-ray devices or CBCT) and even videos for surgery or dental procedures filmed by electronic microscopes. It is clearly seen how taking and saving dental records have changed over time; still there are many regulations regarding the documentation procedure.

There is big change in how traditional paper forms and dental casts were stored in enormous areas and now this is all replaced with virtual archive or server; how technology transformed the practice into full electronic and digital process completed by few practitioners. In the US, there are legal and guardian issues related to the privacy of information. These records are owned by the practice but still the patient has an access to them, may request copies at any time and has the right to claim a review of the diagnosis, treatment plan or other components. Every team member in the dental care has responsibility with patients’ records. This includes taking the records, securing the information and respecting the confidentiality of patients.

Dental photography is a major key in documenting dental cases. It developed in 1980s for dental hygiene sessions to raise the awareness toward dental health. The photos were routinely taken by dental assistants to show the patients their problems in a quick and easy way. Digital photography helped in taking and merging dental images to explain to the patient the extent of dental problems in an efficient way with on-time feedback. In addition, the images can be edited by adding smiles from smile-design library so the patients can expect their treatment results before starting. The process of capturing (extra- and intraoral) photos can take 3-5 minutes. The images are then imported onto software so the patient can be involved in decisions related to treatment planning and follow-up. A smart use of dental photography is to show the patient some photos of patients who had the same pathology previously and were successfully treated. This is considered a motivational approach especially in presence of big library of images. Dental photography is also used for patients’ education.

In bleaching cases, for example, both patients and doctors can miss or forget the looking and color of teeth before treatment. So, before/after photos are mandatory for evaluation of treatment outcomes. In addition, these photos now play essential role marketing campaigns and legal issues. Dental photography is considered the single most-effective way to document the patient’s situation before treatment and the results after treatments.

In modern practice, digital cameras and smartphone cameras are set in automatic mode; thus, the exposure settings are automatically adjusted according to the surrounding lightness/darkness around the recorded objects. Further fine-tuning of the images can be adjusted by the photographers. Unlike the general idea that adjusting a camera requires a professional photographer, it is possible to achieve reasonable-to-excellent photographs without advanced photography skills. In fact, there are general roles that most of dentists can learn by practice; for example, most of dentists can easily notice that close-up photos without adequate adjustment of light exposure can result in too bright photos, which are unrealistic. The learning curve in digital photography is not steep, the only challenge could be getting used to the process of using the technology. Each dentist should have the digital camera instantly accessible and set up (handy) to avoid wasting much time of an already busy schedule. The dental team, especially assistants and hygienists need must learn all or part of dental photography process, including capturing photos and holding retractors, contrastors and mirrors. Finally, remember that a decent camera is unnecessarily to be expensive, and the pay-offs are great in terms of patients’ education, lab communication, marketing, etc.