The authors have none to acknowledge.

The protocol involves standardized documentation of patients&#39; clinical presentation as routinely administered at Columbia University College of Dental Medicine, New York. No patient data were utilized for this publication; the co-authors R.B and J.M.D.O are depicted in the photographs themselves, illustrating techniques described in this protocol and providing consent to publish the images involved. Replicating the procedure under clinical settings will require written informed consent from the patients.
1. Acquisition of extra-oral photographs
<ol>
	<li>Utilize a ring flash and an extra-oral photography reflector (see Table of Materials) for extra-oral photography.</li>
	<li>Acquire patient&#39;s extra-oral photos with a black background. Use a black velvet cloth for the background to reduce shine or unwanted reflections. 
	NOTE: Alternatively, a white background is acceptable as well. It is recommended that the patient be positioned away from external sources of light (i.e., sunlight through a window).</li>
	<li>Ask the patient to remove the eyewear so that both ears are equally visible. 
	NOTE: Individuals with long hair must tuck their hair behind the ear.</li>
	<li>Position the patient straight across the photographer against the background. Align the patient&#39;s head to ensure that the interpupillary line is parallel to the horizontal frame of the camera viewfinder. 
	NOTE: The photo needs to compromise the superior portion of the patient&#39;s head, and the inferior portion needs to encompass the area just below the thyroid gland (Figure 3A).</li>
	<li>For standard documentation purposes, position the patient at a 90&#176; angle and capture the straight frontal photo and the right-side profile photos (Figure 3B). 
	&#8203;NOTE: Additionally, one may consider adding a left and right photo acquired at a 45&#176; angle for esthetic cases (Figure 3C).
	<ol>
		<li>For each position, consider acquiring three poses: repose, natural smile, and widest smile1,17.</li>
	</ol>
	</li>
</ol>
2. Acquisition of intra-oral photographs
<ol>
	<li>Ask the patient to sit in a dental chair at a 45&#176; inclined position (Figure 4A). Ensure that the photographer is at the patient&#39;s 9 o&#39;clock position with the armamentarium for photography (see Table of Materials) located within arm&#39;s reach. 
	NOTE: Figure 4B illustrates the viewfinder observed in the cameras. They are employed to center the image captured where the image is centered to the middle of the viewfinder (Figure 4C).</li>
	<li>Turn off the dental operatory light to prevent light interference with the photos.</li>
	<li>Acquire frontal photos following the steps below.
	<ol>
		<li>Position the patient in maximal inter-cuspal position (M.I.P.)15.</li>
		<li>Place and position the retractors intra-orally into the mouth and recruit the patient to hold the retractors (Figure 4D).</li>
		<li>Position the operator such that the plane of occlusion of the camera is parallel to the horizontal frame line in the camera&#39;s viewfinder (Figure 4E,F). 
		NOTE: Incorrect position of the retractors can result in distorted images where the capture of the soft tissues can be incomplete (Figure 4G). The resultant images do not represent the entire oral cavity when the occlusal plane is not parallel to the operator. Figure 4H,I demonstrates the effect of operator position on the image acquired.</li>
	</ol>
	</li>
	<li>Acquire buccal left and right intra-oral photos.
	<ol>
		<li>Align the patient&#39;s head toward the operator. For acquiring photos on the patient&#39;s right side, place the retractor in the left side of the patient&#39;s mouth. 
		NOTE: The retractor needs to be placed at the angle of the patient&#39;s mouth without tension (Figure 5A,C).</li>
		<li>Utilize the narrow mirror (see Table of Materials) for the buccal photos. Warm the mirror with a commercially available blow torch before insertion (Figure 5B).</li>
		<li>Insert the mirror into the patient&#39;s mouth parallel with the occlusal plane, gently move to the left buccal vestibule, and rotate 90&#176;. 
		NOTE: The mirror&#39;s edge must be rested gently on the external oblique ridge (Figure 5E,F).</li>
		<li>Use the mirror to stretch the patient&#39;s cheek and, at the same time, reveal a reflection of the buccal surface of the right maxillary and mandibular posterior dentition. Apply the same for the left side.</li>
	</ol>
	</li>
	<li>Acquire occlusal intra-oral photographs.
	<ol>
		<li>Position the retractor in the patient&#39;s mouth. Use the large mirror (see Table of Materials) for capturing this photo. 
		NOTE: The patient is recruited to aid in retracting to reveal the maxillary dentition and the buccal vestibule (Figure 6A).</li>
		<li>Before insertion, warm the mirror using a Bunsen burner and insert it into the patient&#39;s mouth. Request the patient to open the mouth as wide as possible to reveal the entire maxillary dentition from molar to molar in the maxillary (Figure 6B).</li>
		<li>For mandibular occlusal photos, change the retractor positions appropriately to reveal the mandibular dentition and associated buccal vestibule (Figure 6D). Request the patient to roll their tongue to the back of the mouth to show the floor of the mouth (Figure 6F). Warm up the occlusal mirror and subsequently insert it gently against the ventral surface of the tongue.</li>
	</ol>
	</li>
	<li>Acquire lingual intra-oral photographs.
	<ol>
		<li>To view the maxillary palatal sextants15 (Figure 7A), use the retractor to retract the left or right maxillary lip. Warm up the small mirror, insert it in the patient&#39;s mouth, and position it to reveal the palatal surface and the palatal mucosa (Figure 7B).</li>
		<li>To view the mandibular palatal sextants15 (Figure 7C), warm up the small mirror and insert it between the tongue and the lingual surfaces of the mandibular dentition. Gently align the mirror medially to reveal the reflection of the lingual surface of the dentition.</li>
	</ol>
	</li>
</ol>

<ol>
	<li>Wagner, D. J. A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=beginning+guide+for+dental+photography:+a+simplified+introduction+for+esthetic+dentistry.">beginning guide for dental photography: a simplified introduction for esthetic dentistry.</a> Dental Clinics of North America. 64 (4), 669-696 (2020).</li><li>Fung, L., Brisebois, P. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Implementing+digital+dentistry+into+your+esthetic+dental+practice.">Implementing digital dentistry into your esthetic dental practice.</a> Dental Clinics of North America. 64 (4), 645-657 (2020).</li><li>Kalpana, D., Rao, S. J., Joseph, J. K., Kurapati, S. K. R. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Digital+dental+photography.">Digital dental photography.</a> Indian Journal of Dental Research. 29 (4), 507-512 (2018).</li><li>Wander, P. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Dental+photography+in+record+keeping+and+litigation.">Dental photography in record keeping and litigation.</a> British Dental Journal. 216 (4), 207-208 (2014).</li><li>Ahmad, I. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Digital+dental+photography.+Part+1:+an+overview.">Digital dental photography. Part 1: an overview.</a> British Dental Journal. 206 (8), 403-407 (2009).</li><li>Hodson, T. M., Donnell, C. C. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Colour+fidelity:+the+camera+never+lies+-+or+does+it.">Colour fidelity: the camera never lies - or does it.</a> British Dental Journal. 229 (8), 547-550 (2020).</li><li>Morse, G. A., Haque, M. S., Sharland, M. R., Burke, F. J. T. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+use+of+clinical+photography+by+U.K.+general+dental+practitioners.">The use of clinical photography by U.K. general dental practitioners.</a> British Dental Journal. 208 (1), 1 (2010).</li><li>Whitehouse, W., Silva, F. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=.">.</a> Full frame vs. crop sensor: Which format is best for you. , (2022).</li><li>Sajjadi, S. H., Khosravanifard, B., Moazzami, F., Rakhshan, V., Esmaeilpour, M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Effects+of+three+types+of+digital+camera+sensors+on+dental+specialists'+perception+of+smile+esthetics:+a+preliminary+double-blind+clinical+trial.">Effects of three types of digital camera sensors on dental specialists' perception of smile esthetics: a preliminary double-blind clinical trial.</a> Journal of Prosthodontics. 25 (8), 675-681 (2016).</li><li>Moussa, C., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Accuracy+of+dental+photography:+professional+vs.+smartphone's+camera.">Accuracy of dental photography: professional vs. smartphone's camera.</a> BioMed Research International. 2021, 3910291 (2021).</li><li>Liu, F. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=.">.</a> Dental Digital Photography. , 1622-1627 (2019).</li><li>Ahmad, I. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Digital+dental+photography.+Part+5:+lighting.">Digital dental photography. Part 5: lighting.</a> British Dental Journal. 207 (1), 13-18 (2009).</li><li>Desai, V., Bumb, D. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Digital+dental+photography:+a+contemporary+revolution.">Digital dental photography: a contemporary revolution.</a> International Journal of Clinical Pediatric Dentistry. 6 (3), 193-196 (2013).</li><li>Ahmad, I. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Digital+dental+photography.+Part+6:+camera+settings.">Digital dental photography. Part 6: camera settings.</a> British Dental Journal. 207 (2), 63-69 (2009).</li><li>Ahmad, I. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Digital+dental+photography.+Part+8:+intra-oral+set-ups.">Digital dental photography. Part 8: intra-oral set-ups.</a> British Dental Journal. 207 (4), 151-157 (2009).</li><li>Ahmad, I. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Digital+dental+photography.+Part+10:+printing,+publishing+and+presentations.">Digital dental photography. Part 10: printing, publishing and presentations.</a> British Dental Journal. 207 (6), 261-265 (2009).</li><li>Ahmad, I. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Digital+dental+photography.+Part+7:+extra-oral+set-ups.">Digital dental photography. Part 7: extra-oral set-ups.</a> British Dental Journal. 207 (3), 103-110 (2009).</li><li>Ahmad, I. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Digital+dental+photography.+Part+2:+purposes+and+uses.">Digital dental photography. Part 2: purposes and uses.</a> British Dental Journal. 206 (9), 459-464 (2009).</li><li>Grundy, J. R. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Factors+influencing+innovation+in+general+dental+practice.">Factors influencing innovation in general dental practice.</a> British Dental Journal. 153 (10), 353 (1982).</li><li>Ahmad, I. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Digital+dental+photography.+Part+3:+principles+of+digital+photography.">Digital dental photography. Part 3: principles of digital photography.</a> British Dental Journal. 206 (10), 517-523 (2009).</li></ol>

The authors have no conflicts of interest to disclose.

Traditional evaluation tools in dentistry such as periodontal charting and model impressions of the oral dentition used for generations consistently provide clinical data; however, they have limitations16. Several clinical pathologies and soft tissue presentations are not accurately represented in traditional modalities of dental evaluation. Thereby, electronic documentation via dental photography is now considered a valuable tool. The clinical photographs reveal the patient&#39;s current...

The approach to the clinical practice of dentistry has evolved over the decades to include a conceptual framework of clinical reasoning based on empirical evidence1. As such, digital documentation now serves as an integral part of the framework on which clinical decisions are made, and evolution of care is observed2. The purpose exceeds mere primary legal records and now encompasses a plethora of extensions that include active mode of communication with patients, educational tools for dental members, educators, and colleagues, visual aids for technicians, and finally, effective marketing3.
Dental photography is often mistakenly construed as technically challenging and plagued with hurdles4. Clinicians find incorporating dental photography to be laborious, an additive task to an already complex series of events that generally occur during patient consultations or treatment. Capturing the essence of a treatment can be technically daunting, especially when it involves purchasing a series of equipment and assembling them further. Even more, the tandem application of the equipment and initial learning curve has been known to deter clinicians from adopting this modality routinely. Additionally, clinicians who overcome the initial intimidation find themselves wrought with the intricacies of the environment they are capturing. The oral cavity has several movable and fixed components. The different fields of view, tissue hydration levels, range of access limited by the patient range of opening, and different clinical presentations are a few obstacles to mention. When these get coupled together with already existing, established photography equipment, the task of utilizing photography as a tool is not a priority for clinicians5. However, with recent advances in technology, clinicians can hugely benefit from adopting dental photography, not merely for educational and clinical decisions, but patient treatment visualization and satisfaction through digital smile design6. Incorporating digital records can enhance the planning and execution of complex treatment plans. The standardization of these records allows for direct comparison before and after series, and fosters a digital fingerprint of dental records that captures a patient&#39;s clinical footprint in time7.
The proposed manuscript aims to standardize the approach to dental photography while illustrating the technical aspects and simplifying the methodology to allow clinicians at different levels to adopt and incorporate photography to increase productivity and achieve success. Furthermore, the manuscript illustrates techniques to practice dental photography without the aid of an assistant, in minimal space with inexpensive equipment and constricted areas.
Camera and supporting infrastructure for enhanced digital photography
Camera 
Several different cameras are available for dental photography; however, a digital single-lens reflex (DSLR) or a mirrorless camera is recommended. There are two types of DSLR or mirrorless cameras. A full-frame camera has a sensor size of 36 mm x 24 mm, and a crop-frame 22 mm x 14 mm8 (Figure 1A). For dental photography purposes, crop frame sensors are recommended due to the superior depth of view compared to a full-frame camera9. Depth of view is the distance between the closest and the furthest point in a picture that noticeably appears clear and focused (Figure 1B). Mobile phone cameras are not recommended for routine dental photography. The cameras lack the necessary settings (aperture) to produce adequate intra-oral photographs. Compact cameras, in general, have a micro 4/3 lens. The lens in these cameras is fixed and not interchangeable10. Dental photography explicitly demands a macro lens for enhanced image capturing.
Lens 
A macro lens has the capability of producing proportional images. The observed 1:1 ratio in the lens context is defined as an image observed by a clinician that is reproduced on the camera sensor and therefore captured in a photograph. Telephoto lenses are zoom lenses; one may get distortions incorporated into an image with zoom11. In a dental photograph, oral structures need to be reproduced as accurately as they appear in the patient&#39;s oral cavity, and therefore, macro lenses are well suited for this purpose. Many different macro lenses are available, which differ in focal lengths. A focal length of 85-105 mm is recommended. When acquiring photos, the lens allows one to be in close range with the patient&#39;s anatomy without being too close to the patient during photography (Figure 1C).
Flash 
There are two kinds of camera flashes available. One is mounted on the camera, and the other is a studio strobe light. For dental photography purposes, the former is recommended12. Several such systems are available, producing different lighting effects, influencing the quality of photographs obtained. For simplicity purposes, a ring flash is recommended to be mounted onto the camera.
Mirrors 
Intra-oral mirrors are an essential tool. They permit the capture of specific segments of the oral cavity that are challenging to capture otherwise. Rhodium-coated mirrors are recommended for their enhanced image quality and physiologically accurate clarity13. Alternatively, titanium or steel mirrors set up are employable since they are more durable. However, they do produce images of diminished quality.
Retractors 
These are necessary to allow unimpeded access to the oral cavity structures. Rounded-shaped retractors are recommended as they are easy to implement and allow full retraction of extra-oral structures.
Reflector 
A photographic reflector is recommended since it helps to illuminate the lower mandibular area in an extra-oral portrait photograph, as the site is commonly influenced by shadows.
Others 
Air syringes are commonly used for de-fogging of intra-oral mirrors. A torch is recommended to warm up the mirrors. This ensures that one can capture an image with very little to no help from a second person.
Camera settings and recommendations for intra- and extra-oral photography 
To allow complete control of the camera settings (described below), the camera needs to be set at manual mode and single shot (Figure 2D).
ISO 
ISO translates to how sensitive a camera sensor is to receiving light (Figure 2A). The higher the ISO, the more sensitive the sensor is to receiving light. This, however, is inversely proportional to the image quality obtained. For dental photography purposes, the recommended ISO needs to be set at 100-40014,15 (Figure 2B and Table 1).
Shutter speed 
Shutter speed refers to how fast a camera shutter responds to enable the sensor to capture an image (Figure 2C,D, and Table 1). The recommended shutter speed needs to be set at 1/125 for intra- and extra-oral photography for dental photography purposes14.
Aperture/F-stop 
F-stop refers to the dimensions of opening by the diaphragm of the macro lens. The lower number corresponds to a wider diaphragm opening, resulting in a shallow depth of view. For dental photography purposes, an aperture of F29-32 is recommended for intra-oral photography and F9-11 for extra-oral photography14,15 (Figure 2E-G and Table 1).
White balance 
White balance is defined as the camera sensor&#39;s ability to compensate for color biases influenced by the external light source. For example, an image acquired in the office with yellow light will present warm undertones. The white balance in dental photography needs to be maintained at 5,500 K to obtain physiological representative images14.
Lighting 
Adequate illumination is necessary to acquire physiologically representative images of the oral cavity. The higher the flash ratio (1:1), the stronger the flash output. For dental photography, the illumination on the flash needs to be set at 1:4 or 1:8 ratio since the F-stop is established at 29-3215.
Picture settings 
The picture settings refer to the camera body preset settings for image contrast and saturation. Different settings result in different camera picture styles. Standard or neutral settings are preferred to accurately represent the oral tissues&#39; physiological presentation. Image quality needs to be set at R.A.W. + JPEG fine16. These settings are used to even out high contrast images by selectively adjusting the highlights and shadows. However, an accurate representation of the patients&#39; oral tissues is desired without artificial modification for dental photography purposes.

<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td>Armamentarium for photography</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Buccal Mirror #15- Narrow mirror</td>
			<td>Doctoreyes</td>
			<td>Ultrabright #15</td>
			<td>Width 40 mm with ultrabright coating</td>
		</tr>
		<tr>
			<td>Camera</td>
			<td>Nikon</td>
			<td>D7500</td>
			<td></td>
		</tr>
		<tr>
			<td>Occlusal Mirror #13- Large Mirror</td>
			<td>Doctoreyes</td>
			<td>Ultrabright #13</td>
			<td>Width 70 mm with ultrabright coating</td>
		</tr>
		<tr>
			<td>Ring Flash</td>
			<td>YongNu</td>
			<td>Macro ring lite YN14EX</td>
			<td></td>
		</tr>
	</tbody>
</table>

a standardized approach to extra-oral and intra-oral digital photography

Contemporary dentistry mandates a more comprehensive and personalized analysis of each patient. Technological advances in digital photography have played vital roles in diagnostic accuracy, treatment planning, execution of therapies, and outcome evaluations, including esthetic enhancement. Digital photography also provides an excellent platform for patient education, communication, and co-management of cases with other healthcare providers. However, intra-oral photography often faces challenges such as inaccessibility of areas to be captured, different moveable vs. fixed tissues involved, contamination with saliva or blood, and differing illumination needs on various locations. Thus, a more standardized and systematic approach is proposed for intra- and extra-oral documentation via digital photography to overcome the existing technical challenges. The current work will outline the appropriate equipment specifications (camera bodies, macro lens, and flashes), positions and postures of the operator and patients, proper techniques of tissue retraction, the use of appropriate intra-oral mirrors, and the essential elements such as aperture settings (F-stop), ISO, shutter speed, and white balance. This article aims to provide all dental professionals with an approachable linear array of guidelines to produce simplified and standardized visual tools for more efficient and effective documentation.

Techniques illustrated in the protocol section were employed to acquire a sequence of extra- and intra-oral photographs. Figure 8A demonstrates the patient in different positions. The three composite positions include repose, natural smile, and widest smile. The photographs are taken in the suggested composite positions to illustrate the facial changes observed in the patient while in function. The musculature surrounding the oral cavity is influenced by restorative work performed in the ora...

Watch this Scientific Journal Video about A Standardized Approach to Extra-Oral and Intra-Oral Digital Photography at JoVE.com

A Standardized Approach to Extra-Oral and Intra-Oral Digital Photography

The present protocol describes a method to capture intra- and extra-oral photographs for digital documentation in the clinical practice of dentistry. The protocol highlights all the critical components involved and the commonly utilized settings to capture dental photographs for clinical documentation.

Contemporary dentistry mandates a more comprehensive and personalized analysis of each patient. Technological advances in digital photography have played ...

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6.7K Views.  Columbia University College of Dental Medicine. The present protocol describes a method to capture intra- and extra-oral photographs for digital documentation in the clinical practice of dentistry. The protocol highlights all the critical components involved and the commonly utilized settings to capture dental photographs for clinical documentation. 

Video: A Standardized Approach to Extra-Oral and Intra-Oral Digital Photography

Bronchial Thermoplasty:  A Novel Therapeutic Approach to Severe Asthma

Bronchial thermoplasty is a non-drug procedure for severe persistent asthma that delivers thermal energy to the airway wall in a precisely controlled manner to reduce excessive airway smooth muscle. Reducing airway smooth muscle decreases the ability of the airways to constrict, thereby reducing the frequency of asthma attacks. Bronchial thermoplasty is delivered by the Alair System and is performed in three outpatient procedure visits, each scheduled approximately three weeks apart. The first procedure treats the airways of the right lower lobe, the second treats the airways of the left lower lobe and the third and final procedure treats the airways in both upper lobes. After all three procedures are performed the bronchial thermoplasty treatment is complete.
Bronchial thermoplasty is performed during bronchoscopy with the patient under moderate sedation. All accessible airways distal to the mainstem bronchi between 3 and 10 mm in diameter, with the exception of the right middle lobe, are treated under bronchoscopic visualization. Contiguous and non-overlapping activations of the device are used, moving from distal to proximal along the length of the airway, and systematically from airway to airway as described previously. Although conceptually straightforward, the actual execution of bronchial thermoplasty is quite intricate and procedural duration for the treatment of a single lobe is often substantially longer than encountered during routine bronchoscopy. As such, bronchial thermoplasty should be considered a complex interventional bronchoscopy and is intended for the experienced bronchoscopist. Optimal patient management is critical in any such complex and longer duration bronchoscopic procedure. This article discusses the importance of careful patient selection, patient preparation, patient management, procedure duration, postoperative care and follow-up to ensure that bronchial thermoplasty is performed safely.
Bronchial thermoplasty is expected to complement asthma maintenance medications by providing long-lasting asthma control and improving asthma-related quality of life of patients with severe asthma. In addition, bronchial thermoplasty has been demonstrated to reduce severe exacerbations (asthma attacks) emergency rooms visits for respiratory symptoms, and time lost from work, school and other daily activities due to asthma.

Bronchial thermoplasty is a non-drug procedure for severe persistent asthma that delivers thermal energy to the airway wall in a precisely controlled manner to reduce excessive airway smooth muscle. Reducing airway smooth muscle decreases the ability of the airways to constrict, thereby reducing the frequency of asthma attacks.

Bronchial thermoplasty is a non-drug procedure for severe persistent asthma that delivers thermal energy to the airway wall in a precisely controlled ...

Fundus Photography as a Convenient Tool to Study Microvascular Responses to Cardiovascular Disease Risk Factors in Epidemiological Studies

The microcirculation consists of blood vessels with diameters less than 150 &#181;m. It makes up a large part of the circulatory system and plays an important role in maintaining cardiovascular health. The retina is a tissue that lines the interior of the eye and it is the only tissue that allows for a non-invasive analysis of the microvasculature. Nowadays, high-quality fundus images can be acquired using digital cameras. Retinal images can be collected in 5 min or less, even without dilatation of the pupils. This unobtrusive and fast procedure for visualizing the microcirculation is attractive to apply in epidemiological studies and to monitor cardiovascular health from early age up to old age.
Systemic diseases that affect the circulation can result in progressive morphological changes in the retinal vasculature. For example, changes in the vessel calibers of retinal arteries and veins have been associated with hypertension, atherosclerosis, and increased risk of stroke and myocardial infarction. The vessel widths are derived using image analysis software and the width of the six largest arteries and veins are summarized in the Central Retinal Arteriolar Equivalent (CRAE) and the Central Retinal Venular Equivalent (CRVE). The latter features have been shown useful to study the impact of modifiable lifestyle and environmental cardiovascular disease risk factors.
The procedures to acquire fundus images and the analysis steps to obtain CRAE and CRVE are described. Coefficients of variation of repeated measures of CRAE and CRVE are less than 2% and within-rater reliability is very high. Using a panel study, the rapid response of the retinal vessel calibers to short-term changes in particulate air pollution, a known risk factor for cardiovascular mortality and morbidity, is reported. In conclusion, retinal imaging is proposed as a convenient and instrumental tool for epidemiological studies to study microvascular responses to cardiovascular disease risk factors.

Retinal image analysis is an unobtrusive procedure for visualizing the microcirculation. The impact of cardiovascular disease risk factors can result in changes of retinal vessel calibers. The procedures to acquire fundus images and the steps for calculating the vessel calibers are described.

The microcirculation consists of blood vessels with diameters less than 150 &#181;m. It makes up a large part of the circulatory system and plays an ...

A Methodological Approach to Non-invasive Assessments of Vascular Function and Morphology

The endothelium is the innermost lining of the vasculature and is involved in the maintenance of vascular homeostasis. Damage to the endothelium may predispose the vessel to atherosclerosis and increase the risk for cardiovascular disease. Assessments of peripheral endothelial function are good indicators of early abnormalities in the vascular wall and correlate well with assessments of coronary endothelial function. The present manuscript details the important methodological steps necessary for the assessment of microvascular endothelial function using laser Doppler imaging with iontophoresis, large vessel endothelial function using flow-mediated dilatation, and carotid atherosclerosis using carotid artery ultrasound. A discussion on the methodological considerations for each of the techniques is also presented, and recommendations are made for future research.

The present article describes the methodological considerations for several non-invasive assessments of vascular function and morphology that are commonly used in medical research to assess different stages of atherosclerosis.

The endothelium is the innermost lining of the vasculature and is involved in the maintenance of vascular homeostasis.  Damage to the endothelium may ...

A Hydrogel Construct and Fibrin-based Glue Approach to Deliver Therapeutics in a Murine Myocardial Infarction Model.

The murine MI model is widely recognized in the field of cardiovascular disease, and has consistently been used as a first step to test the efficacy of treatments in vivo1. The traditional, established protocol has been further fine-tuned to minimize the damage to the animal. Notably, the pectoral muscle layers are teased away rather than simply cut, and the thoracotomy is approached intercostally as opposed to breaking the ribs in a sternotomy, preserving the integrity of the ribcage. With these changes, the overall stress on the animal is decreased. 
Stem cell therapies aimed to alleviate the damage caused by MIs have shown promise over the years for their pro-angiogenic and anti-apoptotic benefits. Current approaches of delivering cells to the heart surface typically involve the injection of the cells either near the damaged site, within a coronary artery, or into the peripheral blood stream2-4. While the cells have proven to home to the damaged myocardium, functionality is limited by their poor engraftment at the site of injury, resulting in diffusion into the blood stream5. This manuscript highlights a procedure that overcomes this obstacle with the use of a cell-encapsulated hydrogel patch. The patch is fabricated prior to the surgical procedure and is placed on the injured myocardium immediately following the occlusion of the left coronary artery. To adhere the patch in place, biocompatible external fibrin glue is placed directly on top of the patch, allowing for it to dry to both the patch and the heart surface. This approach provides a novel adhesion method for the application of a delicate cell-encapsulating therapeutic construct.

This protocol aims to alleviate the limitation of poor cell engraftment for stem cell treatment of myocardial infarctions through the use of a hydrogel system and a fibrin-based glue. With this approach, cell-to-tissue contact post-infarction can be maintained, increasing the therapeutic potential of beneficial agents at the site of injury.

The murine MI model is widely recognized in the field of cardiovascular disease, and has consistently been used as a first step to test the efficacy of ...

Smartphone Fundus Photography

Smartphone fundus photography is a simple technique to obtain ocular fundus pictures using a smartphone camera and a conventional handheld indirect ophthalmoscopy lens. This technique is indispensable when picture documentation of optic nerve, retina, and retinal vessels is necessary but a fundus camera is not available. The main advantage of this technique is the widespread&#160;availability of smartphones that allows documentation of macula and optic nerve changes in many settings that was not previously possible. Following the well-defined steps detailed here, such as proper alignment of the phone camera, handheld lens, and the patient&#39;s pupil, is the key for obtaining a clear retina picture with no interfering light reflections and aberrations. In this paper, the optical principles of indirect ophthalmoscopy and fundus photography will be reviewed first. Then, the step-by-step method to record a good quality retinal image using a smartphone will be explained.

Fundus photography normally requires specialized fundus cameras that are not always available in all clinical settings.&#160;Here, a simple method to record ocular fundus images using a smartphone camera and a conventional high-plus handheld indirect ophthalmoscopy lens is described.

Smartphone fundus photography is a simple technique to obtain ocular fundus pictures using a smartphone camera and a conventional handheld indirect ...

A Minimally Invasive Model to Analyze Endochondral Fracture Healing in Mice Under Standardized Biomechanical Conditions

Bone healing models are necessary to analyze the complex mechanisms of fracture healing to improve clinical fracture treatment. During the last decade, an increased use of mouse models in orthopedic research was noted, most probably because mouse models offer a large number of genetically-modified strains and special antibodies for the analysis of molecular mechanisms of fracture healing. To control the biomechanical conditions, well-characterized osteosynthesis techniques are mandatory, also in mice. Here, we report on the design and use of a closed bone healing model to stabilize femur fractures in mice. The intramedullary screw, made of medical-grade stainless steel, provides through fracture compression an axial and rotational stability compared to the mostly used simple intramedullary pins, which show a complete lack of axial and rotational stability. The stability achieved by the intramedullary screw allows the analysis of endochondral healing. A large amount of callus tissue, received after stabilization with the screw, offers ideal conditions to harvest tissue for biochemical and molecular analyses. A further advantage of the use of the screw is the fact that the screw can be inserted into the femur with a minimally invasive technique without inducing damage to the soft tissue. In conclusion, the screw is a unique implant that can ideally be used in closed fracture healing models offering standardized biomechanical conditions.

This protocol describes a minimally invasive osteosynthesis technique using an intramedullary screw for standardized stabilization of femur fractures, which can be used to analyze endochondral bone healing in mice.

Bone healing models are necessary to analyze the complex mechanisms of fracture healing to improve clinical fracture treatment. During the last decade, an ...

DIPLOMA Approach for Standardized Pathology Assessment of Distal Pancreatectomy Specimens

Pancreatic ductal adenocarcinoma (PDAC) is one of the most lethal malignant cancers. A minority (20%) of PDACs are found in the pancreatic body and tail. Accurate pathology assessment of the pancreatic specimen is essential for providing prognostic information and it may guide further treatment strategies. The recent 8th edition of the American Joint Committee on Cancer/Union for International Cancer Control (AJCC/UICC) staging system for pancreatic tumors has incorporated significant changes to tumor (pT) stage, which is predominantly based on tumor size. This change emphasizes the importance of careful block selection. Owing to the greater prevalence of tumors in the head of the pancreas, efforts are made to standardize the assessment of pancreatoduodenectomy specimens. However, consensus regarding the macroscopic assessment of distal (i.e., left) pancreatectomy specimens is lacking. The DIPLOMA approach includes the standardized measurement of pancreas and other resected organs, inking of relevant surgical margins and anatomical surfaces without removing covering layers of fat, measurement of tumor size (for T-stage), together with assessment of splenic vessel involvement (and other organs if present). All relevant margins are assessed, and relevant blocks are selected to confirm these parameters microscopically. The current protocol describes a standardized approach to the macroscopic assessment of distal pancreatectomy specimens. This approach was developed during several meetings with pathologists and surgeons during the preparation phase for an international multicenter trial (DIPLOMA, ISRCTN44897265), which focuses on radicality of distal pancreatectomy for pancreatic ductal adenocarcinoma. This standardized approach can be instrumental in the design of studies and will uniform reporting on the outcomes of distal pancreatectomy. The described technique is used in the DIPLOMA trial for pancreatic ductal adenocarcinoma but may also be useful for other indications.

The current study highlights a standardized approach to the macroscopic assessment of distal pancreatectomy specimens for pancreatic ductal adenocarcinoma, with special emphasis on the measurement of pancreatic dimensions and those of other organs, inking of margins, measurement of tumor size and proximity to margins, lymph node sampling and block selection.

Pancreatic ductal adenocarcinoma (PDAC) is one of the most lethal malignant cancers. A minority (20%) of PDACs are found in the pancreatic body and tail. ...

Standardized Histomorphometric Evaluation of Osteoarthritis in a Surgical Mouse Model

One of the most prevalent joint disorders in the United States, osteoarthritis (OA) is characterized by progressive degeneration of articular cartilage, primarily in the hip and knee joints, which results in significant impacts on patient mobility and quality of life. To date, there are no existing curative therapies for OA able to slow down or inhibit cartilage degeneration. Presently, there is an extensive body of ongoing research to understand OA pathology and discover novel therapeutic approaches or agents that can efficiently slow down, stop, or even reverse OA. Thus, it is crucial to have a quantitative and reproducible approach to accurately evaluate OA-associated pathological changes in the joint cartilage, synovium, and subchondral bone. Currently, OA severity and progression are primarily assessed using the Osteoarthritis Research Society International (OARSI) or Mankin scoring systems. In spite of the importance of these scoring systems, they are semiquantitative and can be influenced by user subjectivity. More importantly, they fail to accurately evaluate subtle, yet important, changes in the cartilage during the early disease states or early treatment phases. The protocol we describe here uses a computerized and semiautomated histomorphometric software system to establish a standardized, rigorous, and reproducible quantitative methodology for the evaluation of joint changes in OA. This protocol presents a powerful addition to the existing systems and allows for more efficient detection of pathological changes in the joint.

The current protocol establishes a rigorous and reproducible method for quantification of morphological joint changes that accompany osteoarthritis. Application of this protocol can be valuable in monitoring disease progression and evaluating therapeutic interventions in osteoarthritis.

One of the most prevalent joint disorders in the United States, osteoarthritis (OA) is characterized by progressive degeneration of articular cartilage, ...

Rodent Heart and Brain Tissue Preparation for Digital Macro Photography after Ischemia-reperfusion

Macro photography is applicable for imaging various tissue samples at high magnification to perform qualitative and quantitative analyses. Tissue preparation and subsequent image capture are steps performed immediately after the ischemia-reperfusion (IR) experiment and must be performed in a timely manner and with appropriate care. For the evaluation of IR-induced damage in the heart and brain, this paper describes 2,3,5-triphenyl-2H-tetrazolium chloride (TTC)-based staining followed by macro photography. Scientific macro photography requires controlled lighting and an appropriate imaging setup. The standardized methodology ensures high-quality, detailed digital images even if a combination of an inexpensive up-to-date digital camera and macro lens is used. Proper techniques and potential mistakes in sample preparation and image acquisition are discussed, and examples of the influence of correct and incorrect setups on image quality are provided. Specific tips are provided on how to avoid common mistakes, such as overstaining, improper sample storage, and suboptimal lighting conditions. This paper shows the appropriate methodology for rat heart and brain tissue slicing and staining and provides guidelines for establishing lighting and camera setups and photography techniques for high-resolution image acquisition.

Presented here is a protocol for the standardized methodology of rodent tissue preparation after the ischemia-reperfusion experiment and guidelines for establishing lighting and camera setups for high-resolution image acquisition. This method is applicable to all experimental small-animal organ photography.

Macro photography is applicable for imaging various tissue samples at high magnification to perform qualitative and quantitative analyses. Tissue ...

Precision of In Vivo Quantitative Tooth Wear Measurement Using Intra-Oral Scans

Quantitative wear measurement is of increasing interest for measuring tooth wear progression. However, most research on quantitative wear measurement has focused on simulated wear or scanned gypsum casts. A 3D Wear Analysis (3DWA) protocol has been developed that analyzes tooth wear in vivo through intra-oral scanners available to dental clinicians. This study investigated the precision of the 3DWA protocol for measuring wear through maximum height loss (mm) and volume change (mm3). Observational prospective wear data from 55 patients were analyzed after 0-1-, 0-3-, and 0-5-year intervals to determine rates of wear, and convenience samples were chosen to test the protocol&#39;s precision on dentitions scanned twice in one sitting and its intra- and inter-rater precision on scans with 0-3- and 0-5-year intervals. Scans were made using intra-oral scanners (IOS) and superimposed using 3D measurement software. T-tests were performed to determine the structural and random error, and trimmed ranges were calculated to interpret the error. For protocol precision, the mean difference was 0.015 mm (-0.002; 0.032, p = 0.076) for height and -0.111 mm3 (-0.250; 0.023, p = 0.101) for volume. The duplicate measurement error was 0.062 mm for height and 0.268 mm3 for volume. The height measurements were precise enough to measure wear after intervals of 0-3 or 0-5 years; however, volume measurements were susceptible to procedural error and operator sensitivity. The 3DWA protocol is precise enough to adequately measure tooth height loss after intervals of a minimum of 3 years or in patients with severe wear progression, but it is not suited to measuring volumetric changes.

Precision of In Vivo Quantitative Tooth Wear Measurement Using Intra-Oral Scans

Quantitative wear measurement is a method of increasing importance in measuring tooth wear progression. We here describe a protocol, its precision, and its intra/inter-rater precision for the acquisition and superimposition of repeated in vivo scanned dentitions in patients with moderate to severe wear, reporting on both height and volume measurements.

Quantitative wear measurement is of increasing interest for measuring tooth wear progression. However, most research on quantitative wear measurement has ...