Dr. David Eshom • (858) 455-9151[email protected]

Words That Go With Pictures- Dental

The following is an EXAMPLE of the use of pictures for discussion of disease and optional treatment. Doctors could use this method as a way of presenting the possibilities of improved health and cosmetics in an ethical and relaxed manner for the patient and doctor. The patient example is geared around the condition and pictures presented and is only one doctor’s view of what should be presented. Each doctor will have their own philosophies of treatment and what is in the best interest of the patient. The great thing about the photos is that they fit whatever treatment is recommended by each doctor’s individual preferences.

Cosmetic Diagnosis


I use the above photographs of my patients and treatment planning principles for exam discussions with all exams: cosmetic, orthodontic, general and restorative dentistry. You don’t know where your diagnosis is going to go, so like an athlete, you have to be ready to you get the ball. The patient should lead the discussion so going through these steps and pictures lets you do the co-diagnosis with the patient with the upmost flexibility. Health is priority and if there is disease (caries, perio, etc.) then that is where the conversation goes first and the pictures will do the job of showing that problem. Often though, dental health and esthetics overlap as you discuss what the result of restoring the patient’s health will look like. Here is where the opportunity to show the possibilities of a better smile with more teeth are treated with cosmetic dentistry or orthodontics. If there is good oral health, then a cosmetics or orthodontic discussion could proceed based on the patient’s desires. Cosmetics can branch in two directions, orthodontics or restorative (bonding, veneers, crowns, implants). In any of dentistry’s possible solutions these six pictures let the patient see their condition and ask questions and let you explain consequences and discuss solutions.

New patient exam sequence and experience

The new patient has been interview, given a tour of the office and seated in the dental chair. X-rays and photos are taken by the assistant. Before the exam, the doctor starts getting to know patient and while talking to face-to-face, transitions into the beginning of the exam by saying:

“Our exams are very different and, in my opinion, more thorough than other dental offices. I am going to check your dental health by examining your teeth, bone, soft tissues and jaw joint. We think about your overall health and beauty when we do your exams. I prioritize your dental health and I assume if I see decay or infection you would want me to point that out to you? (The patient nods yes.) If I see something to improve your smile, would you like me to mention the possibilities? (The patient usually nod yes and mentions at least whiter teeth. This is very important because it gives you permission to talk about the appearance of their teeth and smile later in the photo discussion.)

Doctor does the exam and assistant charts. The doctor sits the patient up and goes over the dental health issues: gums, teeth and soft tissues with an intraoral pictures on a monitor, iPad or laptop. This is where most exams end and discussion moves to estimates and insurance coverage. This leads to one-tooth-at-a-time dentistry dictated by insurance limits.


It is important to keep the conversation on what the patient sees and what are their possibilities of improvement. Before the estimate and insurance is brought up, the discussion transitions to the first picture which is the extra oral smile photo.

Smile Picture:

Close Up Smile

I start with this picture because I want the patient to see their smile up close. People at home stare at themselves in the mirror for hours looking at their skin, eyebrows and wayward hairs but they never look at their smiles same way. Yet, based on their smiles, judgments are made as to whether they are pretty or ugly, happy or sad and/or confident or meek based on their often overlooked smile. Most women (sorry to pick on women) will spent an hour or more in front of a mirror every morning making sure her eyebrows are perfect and eye makeup just right before they go out of the house for groceries but their front teeth are crooked and bonding is stained. Patients, men and women, become rudely awakened to this fact when seeing their smile like this for the first time and predictably become their worst critics. This smile picture opens the door to a two way conversation between doctor and patient not only about their dental health and but their appearance like no other method in dentistry.

The smile picture is brought up on the monitor and the discussion starts with:

“What do you think of your smile?” Listen to patient. In this example the patient said she thinking of her teeth whiter and the bonding redone. Then I say,

“We definitely can do that. When I did your exam, I not only thought about your dental health but I thought of what your smile looks like and what it could look like. You told me that your front bonding needed to be redone and you wanted your teeth whiter. Would it also be ok if I told you what would give you your best smile? (Answer is usually yes.) The way I do that is by concentrating on the two most important teeth in your smile first: the two top front teeth. (point to #8/9) Normally the length of you 2 front teeth are the same as your “eye” teeth with the side teeth slightly shorter. I would lengthen them into their best position within your lips so that they display properly and then lengthen the teeth (#7and #10) next to them in the right position next them so they can display their best. (point to reference pic to showing ideal length) I don’t stop there. Your smile is not just 4 teeth. It is 10 or 12 teeth. If I lengthen your 4 front teeth, I want to make sure you have a symmetrical WIDE smile like the one in this picture (reference picture). You do have a wide and symmetrical width so no work needed there. How do you think that would look? At this point, if I trace a line on the edges of your top teeth from right to left, it would follow the curve of your lower lip just like this model. Then I say, “That would look beautiful and be just like Rachel’s smile. (point to reference picture). Did I leave anything out that you saw on your top teeth?

Notice that I used words the patient will understand and not dental terms like root torque, class II, decay, occlusion, mesial, full coverage crown, onlay etc. Pointing on the screen like you are drawing with your finger lets the patient see the “lines” you are trying to develop with their smile. This sets up the rest of the photos and emphasizes other imperfections and unhealthy teeth.

Frontal Retracted, Open:

Retracted Open

This view is invaluable in discussion of the patients concerns and smile design. See the discussion points above. Conversation goes like this:

“So we’ve lengthened your top teeth to the proper position and it blended perfectly to your wide and symmetrical side teeth. The top will be looking great and be healthy. Next, we just have to straighten or veneer your lowers and make them fit more ideally to your bite. Do you see how that will work? This will not only have your teeth look better but will also make them healthier because they will be chewing against each other in a more compatible manner. Any questions?”

Upper Occlusal View:

Upper Occlusal View

This view lets the patient see any misalignment and asymmetry from a different angle. They definitely have never seen themselves from this view so it will reinforce the imperfections in their smile and arch form. The discussion goes like this:

“This is a view looking down on your upper teeth. You can see the rough and worn bonding on the front teeth and cavities we spoke about earlier. The treatment on your top teeth will not only be prettier but will be healthier and long lasting.”

Showing patients a view of themselves they have never seen makes you, in the mind of your patient, not only unique, but displays your knowledge.

Lower Occlusal View:

Lower Occlusal View

Like the upper occlusal view, the lower occlusal view emphasizes the notion of crowding and wear in the patient’s eye. Use the same words as in the upper occlusal view, but also point out the calculus or tartar that the patient may see or feel. Also evident on this view is the posterior decay, old leaking filling and wear.

Frontal biting retracted View:

Retracted Biting

At this point the patient is realizing how much you know and how far their teeth are from ideal. It is important to summarize some of the treatment discussed that will improve their health and smile. Conversation goes like this:

“Here are your teeth biting. You can see lengthening your 4 front teeth will make them more venerable to chipping or breaking when you chew or grind. You can also see that in order to straighten and move down the uppers to be level the lowers need to be leveled too. It is important that the teeth fit compatibly so you have less wear and avoid breaking fillings and teeth as you age.”

Double motivate: discuss health treatment that helps beauty and beauty treatments that help health.

Full Face View:

Full Face

It is time to bring it all together. We started with a close up a smile and teeth that your patient never knew they had even though they have been there for their lifetime. The teeth look ugly and twisted and we showed them the individual treatments that when combined will generate a healthy and beautiful smile. The conversation goes like this:

“Now I am showing you the most important picture- a picture of you and your smile. I want to check myself and with you to make sure the individual tooth treatments we suggested in earlier pictures will result in a beautiful and healthy smile at the end of your treatment with us. We talked about your front teeth and make them longer and blending them into your already wide smile. This will give you a straight wide smile and the edges will follow the curve of your lower lip. Your lower teeth will be level and straight to match the uppers. Don’t you think that will look amazing? (Wait for patient to answer) Is there anything I else? Can I answer any questions? Great. I think it will look absolutely amazing and I hope to see you back soon. (Financial coordinator takes over at this point)”

Other verbal descriptions:

When describing using the upper 2 front teeth I say:

“Putting the upper two front teeth in the right place is like if you were building a house on a view. If you had an ocean view lot, you would put the window with the view up first and then build the kitchen and living spaces around the that view. It is like that with your smile. The windows with the view are your two front teeth and we build your smile around making them look their best.”

Even though a patient’s teeth are crowded and misaligned, they may have beautiful teeth individually. They are down on their smile so I brighten them up by complimenting the glossy shine, translucency and facial anatomy. I say the following:

“You have beautiful teeth individually. I would love to have that color, shine and translucency in my teeth. I tell people with individual teeth as beautiful as yours that they have expensive furniture in their mouths. All we have to do is rearrange them and you will have a smile that we can put on the cover of Home and Garden magazine.”

Invisalign Photography Resources

David Eshom, D.D.S.
8899 University Center Lane Suite 245
San Diego, CA 92122
858 455-9151 officeFor Questions:
Cell/Text 858 204-2780
[email protected]

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