Title: Improving the quality of orthodontic clinical photography: A four cycle quality improvement project at the Royal Surrey County Hospital
Abstract:
Problem: Clinical photography is a fundamental component of orthodontic records and is essential for diagnosis, treatment planning, monitoring treatment outcomes, education, and medico-legal documentation. At the Royal Surrey County Hospital (RSCH), clinicians identified concerns regarding the diagnostic quality of intra-oral photographs, particularly buccal views used to assess molar relationships.
Background: National guidance from the Institute of Medical Illustrators (IMI) and the British Orthodontic Society emphasises the importance of standardised orthodontic photography. Errors in image acquisition can distort occlusal relationships and compromise clinical decision-making.
Measurement: A quality improvement project was undertaken using 27 predefined domains based on IMI orthodontic photography standards. Forty consecutive orthodontic patients were assessed during each cycle. A compliance threshold of 90% was established for all domains. Baseline data collection identified deficiencies predominantly within intra-oral photography, including visualisation of the molar relationship, camera angulation in buccal views, and occlusal view orientation.
Design and Strategy: Root cause analysis and driver diagrams were used to identify potential contributors to suboptimal photography. Four Plan-Do-Study-Act (PDSA) cycles were undertaken between 2022 and 2025. Interventions included targeted teaching sessions for Medical Illustration staff, development of educational resources and reference posters, review of photographic techniques, standardisation of protocols, and regular feedback of results.
Results: Extra-oral photography demonstrated high compliance throughout the project and achieved the 90% target across all domains by the final cycle. Significant improvements were observed in several intra-oral domains following implementation of the interventions. The greatest improvements were seen in visibility of the molar relationship, correct camera positioning for buccal photographs, and inclusion of teeth in occlusal views. By the final cycle, most domains achieved or closely approached the predefined standard, demonstrating sustained improvement over time.
Conclusion: This QIP demonstrated that collaborative multidisciplinary interventions can significantly improve the quality of orthodontic clinical photography. Education, standardised protocols, and continuous feedback were associated with sustained improvements in diagnostically important photographic records. Ongoing monitoring is recommended to maintain standards and support future staff training.
