Should Dental Endoscopy Evolve To Be The Gold Standard Of Care?

Kristen Ranaldo, RDH, BSDH making use of Endoscopy

Why has dentistry been treating periodontal disease the same way for the last 50 years? We have seen medicine evolve over time, but there has been such limited advancement in the way we treat periodontitis. For decades, scaling and root planing (SRP) followed by osseous surgery has been considered the gold standard of care. SRP is presently contraindicated and the idea of glassy smooth root surfaces was abandoned years ago. SRP no longer embraces the removal of tooth structure and soft tissue, but there hasn't been a change to our approach to treatment. It is no secret that the basic etiologies of gingivitis and periodontitis are bacterial biofilm and calculus, yet we continue to perform blind SRP. As dentistry advances, we are still using the band-aid approach when treating patients. Is there no other way?

Dr. Lloyd Nattkemper, a periodontist in Monterey, California, purchased the first dental endoscope at AAP in 1993. During one of our discussions, he stated, “No one in the audience had been aware of the technology or had seen what we were seeing before, except with full-thickness flap elevation or on extracted teeth. Roger describes how he and his hygienist, who has carefully trained, were able to effect complete root debridement and see very impressive pocket depth resolution using this device along with ultrasonics and hand instrumentation.

I decided to purchase the device that day—and became one of the first four clinicians in the country to start using it the following Monday.” Three decades later, and just a few hundred dental endoscopes in the United States have been sold. Amazingly, most clinicians do not know what dental endoscopy is nor is it taught in dental or dental hygiene school.

So, what exactly is a dental endoscope? It is an advanced technology that allows the clinician to subgingivally explore and visualize the root surfaces in real-time at 100x magnification. Without the necessity of an incision and sutures, a dental endoscope guides the clinician during the process of debriding the root surface free of plaque and calculus, the treatment for periodontitis. It could also be used diagnostically to identify other problems such as subgingival caries, perforations, external root resorption, overhangs, excess cement, and other disease-causing flaws of the tooth root’s surface that are not always seen on radiographs or previously required surgery to detect. The camera, or fiber, is covered by a single-use sterile sheath, which sits into four area-specific explorers used to deflect the gingiva so the camera and sheath can be inserted into the sulcus. Over the last decade, lasers in dentistry have dominated the industry for both hard-tissue and soft-tissue applications. Although widely used, there are debates concerning the efficacy of laser periodontal therapy. Why is this? Complete removal of biofilm and removal of biofilm-harboring calculus is the gold standard of periodontal care,

Both with a conventional flap and non-surgical periodontal therapy. According to Wright et al. in 2023, premolars and molars are more difficult to debride nonsurgically and more than 60% of molar sites can present with residual calculus. Another study reported that more than 90% of cases had deposits of plaque and calculus remaining in sites with pocket depths greater than 5 mm after SRP. It has been proven that the use of a dental endoscope results in significantly less residual calculus on the root surface when compared to tactile evaluation in blind scaling, especially in multirooted sites.

Whether it is non-surgical periodontal therapy or laser-assisted periodontal therapy, it’s vital to utilize dental endoscopy in tandem with these procedures for greater pocket reduction and more predictable results. Dental endoscopy has been around since the 1980’s, however, the advancements in the technology were limited, until recently. The most current endoscope, PerioView, was brought to the market by Dr. Aziz Bohra, a periodontist himself. Dr. Bohra revolutionized his practice with dental endoscopy over the past thirteen years. By leveraging his hygiene team, he was able to expand his practice while maintaining his hygienists

The PerioView endoscope pairs the advancement of technology with state-of-the-art video imaging and display that allows up to 100X more magnification than in the past on an 11”x11” touch screen. This 1.0 mm digital camera lens is 160k pixels, equivalent to 12MP, and allows an area of about 3-5 square mm with a depth of field of 1mm to 20mm. The all-in-one medical-grade computer monitor records still images and video for high-resolution results and patient records. Moreover, PerioView enables multiple services to be applied simultaneously, streamlining practice operations and increasing patient satisfaction. Not only is dental endoscopy more effective, it is less invasive leading to higher patient acceptance.

With this minimally invasive, precise approach, the patient will experience a shorter recovery time, less sensitivity, less recession, and reduced need for re-treatment. Dental endoscopy is not just an SRP alternative, it is a microsurgery that can be performed by itself, with laser-assisted periodontal therapy, and with biologic modifiers. As a mostly hygienist-operated technology, dental endoscopy empowers our profession and allows for career growth. Going on a decade of dental endoscopy experience, it has become something I cannot practice without. Once you see what you are missing in furcations, distal line angles, at the CEJ, and crown margins, it makes your instrument different. Most of us have not picked up our right and left ultrasonics since school, and they are necessary when treating a periodontal patient. With proper implementation, I believe dental endoscopy could benefit all dental and periodontal practices and is a revolutionary approach to treating the high prevalence of periodontal disease.

Medicine is always advancing, shouldn’t dentistry follow suit? Dental endoscopy deserves recognition as the new gold standard of care, ensuring precise calculus removal through a minimally invasive approach and delivering consistently reliable outcomes. With this knowledge in mind, how do you envision treating your patients?

References

1. Wright HN, Mayer ET, Lallier TE, Maney P. Utilization of a periodontal endoscope in nonsurgical periodontal therapy: A randomized, split-mouth clinical trial. J Periodontol. 2023;94:933–943. https://doi.org/10.1002/JPER.22- 0081