Seeing what your patient sees

on 25th April 2019


Patients may be seeing a completely different image to what you’re seeing, Chloe Davies and Ian Hutchinson say.

When you see something you believe it, however, we need to be more aware that our eyes can lie to us. The clue is in the word ‘be-lie-ve’. What one person’s eyes see and perceive almost without distinction is not the same as another person. How can we help to align what the patient and the clinician sees from one of the most trusted senses in human nature – sight?

This article aims to give you an insight into how we can better understand and appreciate the patient’s views and concerns. As a fourth-year dentistry student I have seen only a small range of patients in the grand scheme of things. Often a patient comes in with a pain-related complaint or they’re aesthetically motivated. Of these cases, some of them you can understand and options immediately spring to mind. But are we seeing the problem truly as the patient is describing it or do we just think we are seeing the full picture?

In our daily life we can see many optical illusions that trick our minds. Sometimes we are expecting this and the deception is noticed and sometimes we have no idea it’s even happened. But there is one fundamental difference with what we see and what our patients see that can be rectified.

Looking at a reflection

Figure 1: Frontal photo of patient smiling – what the clinician sees

The best way this was explained was through a patient case in practice. Firstly, cast your attention to Figure 1.

We are looking at what is seen in the image but the patient is looking at a reflection of this image in a mirror. Explaining why sometimes you’ll take a photo such as a ‘selfie’ and you’ll think it’s going to turn out great but actually the image flips and that’s the game changer.

To research this further, Heinrich Wolfflin, an art historian and writer on the topic of aesthetics, pointed out that pictures change appearance and lose meaning when turned into their mirror images. He realised that this happens because pictures are read from left to right.

Gaffron relates this phenomenon to the dominance of the left cerebral cortex, which contains the higher brain centres for speech, writing and reading. Therefore, if this dominance applies to the visual centre also, then there could be a difference in our awareness of visual data – in favour of data that is seen within the right visual field as opposed to the left. Vision to the right would be more articulate, or louder, which explains why objects on the right appear more conspicuous.

To re-visit the patient from earlier – this is what she was seeing – the gingival zeniths don’t flow in a smooth arc – simple smile design principles, the centre line is shifted, the lateral incisor and canine kicked out – this is what she was seeing in the mirror and why it is more obvious to her and not to us.

So, we decided to do two simple experiments. In the first we took 10 images of asymmetrical smiles and asked 10 patients to say which was the most attractive, left or right. In the second, we took 10 clinicians and asked them to look for problems, but they could only look at the image briefly as we tend to have a methodical approach to examining, especially when we know there are ‘things’ that need to be corrected.

What we found was that the most attractive smiles were when the ‘abnormality’ was on the left as opposed to the right.

Interestingly, when the abnormality was on the left it was still detected but when on the right, more so. Abnormality on the left detection rate was 62%, abnormality on the right detection rate was 84%.

Figure 2: Reversed image of patient

Take home message…

What can we take from this to help improve patient communication and treatment outcome?

  1. It is advisable to take the patient’s photo and flip it so that you can see what the patient is seeing – it may be an obvious problem like a buccally positioned canine, but there may also be some other, less obvious issues as well, like the gingival zeniths

    What will you gain from this?

  2. We all know what can happen when views of the clinician and patients are not aligned, treatment is carried out with what you think is fully informed consent. But how can it be if you’re looking at different images and ultimately expecting different results. If you can see the same image and hope for the same outcome, you could save yourself more time in the long run.


Chloe Davies is a fourth-year dental student.

Ian Hutchinson is a specialist orthodontist.


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