|Year : 2010 | Volume
| Issue : 4 | Page : 241-244
More than meets the eye: Digital fraud in dentistry
SA Rao1, N Singh2, R Kumar3, AM Thomas3
1 PG Resident, Department of Pediatric Dentistry, Christian Dental College, Brown Road, Ludhiana - 141 008, Punjab, India
2 Professor, Department of Pediatric Dentistry, Christian Dental College, Brown Road, Ludhiana - 141 008, Punjab, India
3 Principal and Professor, Department of Pediatric Dentistry, Christian Dental College, Brown Road, Ludhiana - 141 008, Punjab, India
|Date of Web Publication||25-Jan-2011|
S A Rao
Department of Pediatric Dentistry, Christian Dental College, Brown Road, Ludhiana - 141 008, Punjab
| Abstract|| |
Introduction: Digital photographs play a substantial role in the presentation and validation of clinical cases for documentation and research purposes in esthetically oriented professions such as dentistry. The introduction of sophisticated cameras and "easy to use" computer software readily available on today's market has enabled digital fraud to emerge as a common and widely used practice. Hence, it is essential that both dentists and editorial circles are aware and cautious with regard to the possibility of digital fraud. Materials and Methods: A set of 10 routine "pre-" and "post" treatment dental procedure photographs were taken and randomly manipulated using standard desktop software. A team of 10 dental professionals were selected and each one of them was individually requested to review and evaluate the authenticity of the photographs. Results: An assessment of expert opinion revealed an overall sensitivity of 60% and a sensitivity of 15% in correctly identifying a manipulated photograph, which is considered low. Furthermore, there was poor interobserver agreement. Conclusion: Advanced technology that is easily available has resulted in adept digital fraud that is difficult to detect. There is a need for awareness among both dental practitioners and the editorial circle regarding misrepresentation due to image manipulation. It is therefore necessary to follow a skeptical approach in the assessment of digitalized photos used in research and as a part of clinical dentistry.
Keywords: Digital photographs, computer software, sophisticated cameras, morphing
|How to cite this article:|
Rao S A, Singh N, Kumar R, Thomas A M. More than meets the eye: Digital fraud in dentistry. J Indian Soc Pedod Prev Dent 2010;28:241-4
|How to cite this URL:|
Rao S A, Singh N, Kumar R, Thomas A M. More than meets the eye: Digital fraud in dentistry. J Indian Soc Pedod Prev Dent [serial online] 2010 [cited 2013 Jun 19];28:241-4. Available from: http://www.jisppd.com/text.asp?2010/28/4/241/76149
| Introduction|| |
Digital photography plays a significant role in clinical specialities, which lays emphasis on esthetics such as dentistry. Clinical photographs allow the dentist to carefully study the patient's dental patterns and plan treatment without the need of the patient being present. This information obtained from photographs greatly aids the dentist in formulating the best possible treatment plan for the patient. The current "best practice" is a full set of extra- and intraoral photographs, both at the start and at the completion of treatment and, ideally, some midtreatment photographs showing key-stages in treatment.  These photographs not only act as adjuncts for treatment planning but also help in maintaining records that can be used further for research and publication purposes. Also, the growing importance of the need of such records for medicolegal reasons cannot be overemphasized.
In the past, conventional photographic equipment for orthodontic images produced good image quality, was very reliable and user-friendly and was relatively inexpensive.  A conventional 35-mm slide is thought to contain the equivalent of 25-30 million pixels of information, which is a long way to go for many digital images to be serious competition.
However, well-recognized problems with conventional photographic techniques are the cost of developing and processing films, the time required for processing and physical storage of all the patients slides or prints and no instant results.
The obvious drawbacks in conventional photography led to the development and popularization in digital technology. Digital cameras are advantageous in that the images can easily be transferred onto computers and stored for later reference and use. These images can also be edited and manipulated to enhance diagnosis and for better clarity. Such manipulation is possible due to the availability of image manipulation software, which are of reasonable expense and some of which can also be downloaded from the Internet.
However, in the present times, this accessibility of technology to the general public has resulted in the unsolicited emergence of fraud. Skilful manipulation of photographs to display favorable results have become a common practice and is difficult to detect. Hence, there is a need for growing awareness among practitioners and reviewers to identify and acknowledge the possibility of digital fraud.
Consequently, the present study was conducted to assess the awareness of digital fraud among randomly selected clinicians and their ability in detecting such cases.
| Materials and Methods|| |
In this study, we selected 10 participants who required dental treatment, mainly esthetic, orthodontic or a surgical procedure. After obtaining informed consent of all the participants, 10 pre- and 10 posttreatment photographs were obtained. All the photographs were taken using one standard camera (Nikon D80, London, UK ) for all the photographs. Five of these images were randomly selected and then manipulated using readily available image manipulation software Picasa software inc, USA ( free online download from Google).
The manipulations performed included reducing the prominence of postoperative blemishes and scars on preoperative photograph. In a few of the photographs, the treatment procedure to be performed was carried out on the computer on the preoperative photograph rather than on the patient. All these digital images, including the nonmanipulated ones, were then reprinted on a 4 x 6 inch photographic paper.
A selection of 30 dentists from varying academic settings were requested to examine the photographs. Those who asked for digital copies were given the same. To safeguard dentist objectivity, they were informed that within each series of 10 photographs, there were present both manipulated as well as original photos that were randomly inserted and that no assumptions should be made on viewing them. The dentists were then asked to identify the manipulated photographs and state in which way they thought the images had been altered.
The dentist sensitivity in identifying the fraudulent photographs was calculated for each of the dentists and later was compared with each other.
| Results|| |
There were five manipulated and five unmanipulated photographs in the series. Dentists could not correctly classify all unmanipulated images as such, and were unable to correctly identify the manipulated photographs, classifying the majority of them as unmanipulated.
Expert assessment had an overall accuracy of 49% and a sensitivity of 44% in correctly identifying a manipulated photograph. As there were also false-positive cases (i.e., unmanipulated images being identified as manipulated), the specificity was about 54%. The positive predictive value obtained was 48.89% and the negative predictive value obtained was 49.09%.
| Discussion|| |
The past decade has seen remarkable growth in our ability to capture, manipulate and distribute digital images. The average user today has access to high-performance computers, high-resolution digital cameras and sophisticated photoediting and computer graphics software. And, while this technology has led to many exciting advances in art and science, it has also led to the complication of fraud. 
Photomorphing and manipulation is very easy to commit with the easily available softwares that are easy to be used.  Dentistry relies a lot on photographs not only for records but also largely to educate the patient about various treatment options. Photographic misrepresentation is of course as old as photography itself, having been used, inter alia, to prove the existence of the paranormal in the form of psychic photography and for political propaganda.  It probably was not long after Nic΄ephore Ni΄epce created the first permanent photographic image in 1826 that tampering with photographs began. Some of the most notorious examples of early photographic tampering were instigated by Lenin, when he had "enemies of the people" removed from the photographs.
What has changed in the recent past is that with the advent of digital technology, the ability to perform sophisticated image manipulation has moved from the dark room and the domain of a few highly skilled technicians to any personal computer and any individual with a reasonable knowledge of information technology.
The necessary software is readily available and the knowledge to perform image manipulation can be easily acquired from online tutorials, by purchasing books on digital photography, as well as an increasing number of tutorials in the medical literature.  Importantly, photographic misrepresentation is not confined to postacquisition image manipulation. For example, changing the camera's flash settings or the ambient light can radically change the characteristics of the images. The resulting effect is that two consecutive photographs, taken seconds apart, could be convincingly presented as the before and after results of tooth bleaching.
There are many different ways in which digital images can be manipulated or altered, such as compositing.  It is perhaps the most common form of digital tampering, which involves overlaying of one part of one photograph onto another. An example would be placing teeth from one mouth to another. These manipulations can be performed in Adobe Photoshop, and will take approximately 30 min to complete. The credibility of such a forgery will depend on how well the image components are matched in terms of size, pose, color, quality and lighting. Given a well-matched pair of images, compositing, in the hands of an experienced user, is fairly straight forward.
Another method would be image morphing. This is a digital technique that gradually transforms one image into another image [Figure 1] and [Figure 2]. This morphed sequence is automatically generated once a user establishes a correspondence between similar features in the source and target images. This finds uses specially in morphing orthognathic results using easy-to-use software such as Fantamorph.
The other method would be retouching. This is the method we had used in this study. These manipulations are a simple matter of copying and pasting small regions from within the same image. An example would be removing stains by duplication of the region with a stain-free region: a readymade option in the Picasa software.
One more method would be image enhancement, the most commonly used method. This type of manipulation, unlike compositing, morphing or retouching, is often no more than a few mouse clicks away in Photoshop. While this type of tampering cannot fundamentally alter the appearance or meaning of an image (as with compositing, morphing and retouching), it can still have a subtle effect on the interpretation of an image - e.g., simple enhancements can obscure or exaggerate image details or alter the shade of a tooth in which the image appears to have been taken after treatment or before treatment in cases of bleaching or veneering.
However, a reactionary move back to film photography is neither useful nor would it do much to combat fraud, as it is now quite easily possible to print "hard copies" of digital photographs.
The first step is to raise awareness of it within dental and editorial circles. The best time to recognize a manipulated image is when it is in a high-resolution digital format (i.e., when it has been submitted for publication). It is rather more difficult to recognize a manipulated image from the single-column printed version. Some journals have set out detailed requirements for submission of photographs, requiring them not to have been "altered or retouched in any way." Furthermore, it requires that the "before and after photographs of patients should be standardized in terms of size, position and lighting." 
On the contrary, similar requirements could not however be found in the "Guide to Authors" sections of many dental and maxillofacial journals. A clear standard must be set by various journals and dental schools for the acceptable levels of image correction and strict action to be taken against those found using manipulated images in journals, dental schools and promotional media.
It is important to realize also that not all image manipulations are misrepresentations. It may be very legitimately necessary to "crop" a picture, remove patient labels, cover eyes or add arrows and annotation to an image. It may similarly be considered a legitimate use of digital photography to remove a distracting background to enhance clarity. ,
Today's technology allows digital media to be altered and manipulated in ways that were simply impossible 20 years ago. Tomorrow's technology will almost certainly allow for us to manipulate digital media in ways that today seem unimaginable. And, as this technology continues to evolve, it will become increasingly more difficult for many to keep pace with understanding its power and its limits. The use of digital images in dentistry has considerable advantages, and the ease with which it can be abused must not be allowed to undermine this valuable method of communication.
| References|| |
|1.||Sandler PJ. Profiting from photography. Angle Society Newsletter 2000. p. 26-7. |
|2.||Sandler PJ, Murray AM. Recent developments in clinical photography. Br J Orthod 1999;26:269-74. |
|3.||Camarena LC, Guerrero MT. Digitization of photographic slides: simple, effective, fast, and inexpensive method. Ann Plast Surg 2002;48:323-7. |
|4.||Sandler J, Murray A. Clinical photographs: The gold standard. J Orthod 2002;29:158-61. |
|5.||Farid H. Creating and detecting doctored and virtual images: Implications to the child pornography prevention act. Dartmouth College, Computer Science. |
|6.|| Corl FM, Gerland MR, Lawler LP, Fishman EK. A five-step approach to digital image manipulation for the radiologist. Radiographics 2002;22:981-92. |
|7.||Popescu AC, Farid H. Exposing digital forgeries by detecting traces of re-sampling. IEEE Transactions on Signal Processing; 2004. |
|8.||Lyu S, Farid H. How realistic is photorealistic? IEEE Transactions on Signal Processing; 2005. |
|9.||Papel ID, Jiannetto DF. Advances in computer imaging/applications in facial plastic surgery. Facial Plast Surg 1999;15:119-25. |
|10.||Benz C. Digital photography: exposures, editing images, and presentation. Int J Comput Dent 2003;6:249-81. |
|11.||Popescu AC, Farid H. Exposing digital forgeries in color filter array interpolated images. IEEE Transactions on Signal Processing; 2005. |
|12.||Rhodes ND, Southern SJ. Digital operation notes: A useful addition to the written record. Ann Plast Surg 2002;48:571-3. |
|13.||Niamtu J. Techno pearls for digital image management. Dermatol Surg 2002;28:946-50. |
[Figure 1], [Figure 2]