Dental Endoscopy- Seeing is Believing

Two years ago at an American Academy of Periodontology annual session meeting, I listened to two esteemed colleagues describe an endoscopic device that would revolutionize the delivery of periodontal treatment. They discussed how nothing had impacted their practices this much since they began placing implants. They even used phrases like “this represents a new standard of care in periodontal therapy.”  I’m always a skeptic when I hear claims like this, yet here were two well known and nationally recognized peers using these descriptions in a scientific meeting.  Additionally, since I’m somewhat of a technology buff who loves gadgets, I decided our practice needed another expensive piece equipment that could very well soon be collecting dust in a closet somewhere.

The device we purchased is called a Perioscope and is offered by Dentalview, headquartered in Irvine California. So far, it has gathered very little dust since we acquired it in the summer of 2002.

For several years, medical providers have utilized endoscopy for various diagnostic and surgical procedures.  More recently, these technologies have been miniaturized to the point where they can be applied intra-orally and even be used within the gingival sulcus.

This system relies on a narrow, 1 mm diameter endoscope, which is attached to a viewing system.  The viewing system provides for an illumination source, an irrigation source and an LCD monitor where the images are presented.  Since the endoscope is so narrow, it can be utilized to obtain images even in difficult areas to access.  Depending on the distance between the lens and the object being examined, the unit provides magnification between 24 to 48 times.  Some examples include imaging subgingival accretions during root debridement, localizing and diagnosing root fractures or other root anomalies, inspecting subgingival restoration margins, diagnosing root resorptions, and viewing post perforations (all possible etiologic factors in periodontal lesions). While I have used the system with great success in all of the diagnostic situations previously mentioned, I will limit our discussion to its’ use in root debridement.

In a normal periodontal treatment plan, the patient usually undergoes full mouth root planing. Tactile feedback, which is often limited by instrument accessibility, provides the therapeutic endpoint for classical root planing.  The response to the initial debridement is reevaluated at some later date.  If the patient has responded ideally and the disease has been controlled, the patient is transitioned into a periodontal maintenance program.  On the other hand, if the disease is still active, the patient is advised to have periodontal surgery.

Periodontal surgery provides for unparalleled access in vision and instrumentation. By elevating a flap, a surgeon can readily treat most, if not all, of the problems associated with periodontal disease.  Roots can be rendered free of accretions, bone architecture can be improved by recontouring or regeneration and pocket depths can be reduced.  Indeed, periodontal surgery has stood well in evidence-based studies evaluating the efficacy as determined by the preservation of tissue attachment levels. 

However, my experience over the last nine months using the Perioscope leads me to believe there is another option for some periodontal cases.  Using the enhanced imaging system of the Perioscope, a clinician can obtain live video of the root surface while it is being debrided. 

Of course, the accessibility of the dentition anterior to the molars as well as the simpler root morphology makes these sites more responsive to treatment.  From bicuspid to bicuspid, we are observing significant probing depth reductions as well as the elimination of inflammatory parameters.  I am continually amazed that I have been able to detect and remove residual calculus in almost every case in which I use the Perioscope, in locations that had been previously root planed. 

Deep vertical bony defects as well as deep molar furcation sites offer less impressive results due to access issues, and they remain more effectively treated by surgery.  Clearly, the current instrumentation options for these difficult sites remains limited; however, new designs for piezoelectric micro ultrasonic tips and extended reach, narrow tipped curettes are currently being studied.

Some sources report that the basic clinical skills required to gain access to subgingival structures and interpret the images can be acquired with 8 hours of training. In my opinion, mastery of these techniques will take at least 4 to 6 months of clinical experience.  Indeed, after nine months of use, we are still gaining expertise, and as new instrumentation becomes available, we will test and incorporate the most useful designs. 

Presently, endoscope-aided subgingival, non-surgical scaling and root planing is very time consuming. It often takes an hour and thirty minutes for treating one quadrant. With more clinical experience and improved instrumentation, I am sure this will decrease. However, for the patient who is resistant to a surgical treatment plan, it provides a viable option to help control the progression of their periodontal infection.  Most patients in this category enthusiastically accept this as a treatment option and I have likewise incorporated the Perioscope in my practice whenever possible. 

In summary, endoscopically assisted, non-surgical treatment for periodontitis is indicated for those cases where the best quality of subgingival debridement is wanted.  It is ideal for cases where the patient in need of surgical correction declines surgery or presents with a contraindication to surgery. The Perioscope is very useful in areas where surgical pocket elimination would create unesthetic gingival architecture. Lastly, it is also useful in the visual confirmation of subgingival diagnostic dilemmas.  I am excited about this new technology.

Dental Endoscopy C.E. Review for Dental Professionals

As always,  Aymee and I welcome your referrals and would be happy to discuss any case where you think endoscopy may be beneficial for your patient. Your confidence is appreciated!

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