Published on January 25th, 2010 | by
Perioscopy – The new paradigm
Originally published in April/May 2003 edition of Dimensions in Dental Hygeine
The dental endoscope creates the opportunity for successful periodontal therapy and offers the dental hygienist a tool to aid in definitive scaling and root planing.
HUMANS have been cleaning each other’s teeth for at least 3,000 years. Instruments designed for cleaning teeth have been recovered from archeological sites in Greece, Egypt, and Turkey that predate Greek and Roman recorded history.
For all of these years, the basic techniques for subgingival root debridement have not changed. It is remarkable that given all the advances in science and medicine, dental hygienists are currently scaling root surfaces using essentially the same blind instrumentation techniques developed so long ago. Until recently, clinicians were not able to visualize the root surface in deep periodontal pockets during scaling and root planing. But now, the dental hygienist has the ability to see the root surface in real time and can effectively instrument subgingivally with vision.
This is possible with the development of an endoscope (made by DentalView Inc, Irvine, Calif) that is small enough to fit within the gingival sulcus, so the clinician can see the root surface and sulcus contents.1,2 Clinicians can effectively remove all root deposits and biofilm in well-defined, selected sites with the aid of the dental endoscope.3 The unexpected result of cleaning a root surface well is that the gingiva will most often reattach to the root surface—effectively reducing pocket depth and inflammation. This decreases or eliminates the need for periodontal surgery3 in many periodontal pockets where access for the endoscope is feasible and skillful instrumentation can be completed. This procedure is called perioscopy.
The term perioscopy is derived from peri, meaning around, and scope, which means to see. Perioscopy is a definitive periodontal therapy that the dental hygienist can deliver in selected sites. The introduction of the dental endoscope has created a new paradigm for dental hygiene practice.
The Dental Endoscope
The dental hygienist is confronted daily with the uncomfortable realization that, despite strong instrumentation skills and an understanding of root anatomy, the question of whether residual root deposits are left behind within moderate to deep periodontal pockets remains. This uncertainty is well founded because complete removal of all root deposits in periodontal pockets deeper than about 4 mm is impossible with traditional scaling and root planning (SRP).4-10With the dental endoscope, dental hygienists can now visually explore the gingival sulcus, providing the precise location of biofilm, root deposits, granulation tissue, caries, and root fractures.
The endoscope is about 1 meter in length and .99 mm in diameter. It is made up of 10,000 optical and 19 illumination elements. To maintain sterility, a disposable sterile sheath is placed around the endoscope for each patient use. The sheath has a lumen or opening for delivering water into the sulcus to clear blood, biofilm, and other debris from the field of view. The sheath is attached to an explorer-probe (Figure 1) used to guide the endoscope subgingivally. A soft tissue shield is attached to the explorer probe to aid in gently displacing the margin of the gingiva to one side so you can look directly into the sulcus. The image of the root and sulcus contents is projected on a flat screen monitor (Figure 2, page 16) with a magnification of 22x to 48x. The clinician is, therefore, observing the sulcus contents and subgingival root surface using indirect, highly magnified, illuminated vision.
Acquiring skills in instrumentation using the endoscope requires time and effort. Most clinicians are effectively scaling subgingivally with the endoscope within a few weeks and many periodontal pockets begin healing within a few months. Regardless of clinicians’ initial skill level and experience, once they begin to use the dental endoscope, their abilities in root instrumentation improve dramatically. This is obviously because clinicians can directly observe the effectiveness of instrumentation with visual confirmation of deposit removal. Approaches can be modified and new techniques or instruments adopted to successfully remove all visible root accretions.
Explorer probe of the dental endoscope.
The introduction of the dental endoscope has created a new paradigm for dental hygiene practice.
Steps for Successful Perioscopy Therapy
Detecting calculus and biofilms with the endoscope and developing instrumentation skills are both required to achieve a perioscopy clean root surface. This dual skill set is essential to effective perioscopy.
In the process of training hundreds of dental hygienists in perioscopy, it is evident that most dental hygienists can develop the skills necessary for image interpretation and instrumentation. The dentist needs to provide time and resources for the dental hygienist to reach this level of proficiency. It may take the clinician 1 to 2 additional months of using the dental endoscope 2 to 3 hours a week to achieve proficiency in perioscopy.
The best method of assessing the skills of the clinician in achieving the goal of a “perioscopy clean” root is evaluating the clinical result. If the clinician acquires these skill sets and achieves a perioscopy clean root, the effect will be significant healing of the periodontal lesion, probeable pocket depth reduction, and improvement in calibrated attachment level.
Achieving a Subgingival Calculus Index11 of zero (SCI O) is the goal of subgingival instrumentation with the aid of the endoscope. An SCI O is defined as the absence of visible calculus based on indirect, magnified, illuminated vision of the subgingival root surface when viewed with the dental endoscope.11 Using these techniques is an extension of traditional SRP.
Perioscopy is considered after traditional SRP has been completed. Attempting to use the dental endoscope during initial SRP is difficult and impractical. SRP alone and improved patient oral hygiene can resolve many periodontal lesions and are more quickly accomplished than perioscopy. Moreover, the use of the endoscope in moderately inflamed tissue makes viewing the root surface difficult due to hemorrhage and granulation tissue.
Perioscopy is considered when evaluating the patient’s response to initial SRP and oral hygiene instruction. This is usually the point in periodontal therapy where the dentist examines the patient after nonsurgical periodontal therapy and elects to treat nonresponsive sites with periodontal surgery. Perioscopy is an alternative, noninvasive, definitive therapy that serves as a substitute for periodontal surgery in carefully selected sites. It is, therefore, a therapy to consider between SRP and periodontal surgery in the sequence of conventional periodontal therapy.11
In a retrospective study11 of 12 patients who had periodontal surgery treatment planned, the efficacy of perioscopy therapy was demonstrated. These patients had 626 periodontal pockets treated with perioscopy rather than periodontal surgery. These periodontal pockets, ranging from 5 mm to 10 mm in depth, were treated with perioscopy to achieve a perioscopy clean root surface (SCI O) and then the patients were provided periodontal maintenance procedures (PMP) every 3 months thereafter. Note that the perioscopy procedure is performed once, to a level of perioscopy clean, and then the patient is placed back on 3-month PMP. In this study, most periodontal pockets around single rooted teeth healed with significant reduction in probable pocket depth (PPD), an increase in calibrated attachment level (
CAL ), and the elimination of bleeding upon probing. The pocket depths continue to be maintained in the 2 mm-3 mm range after more than 3 years of 3-month PMP alone.11 The following observations were made from this clinical trial.
1. Significantly more reduction in PPD can be achieved with perioscopy in addition to that achieved with traditional SRP (2.25 mm mean over traditional SRP in all sites).
2. Significant gain in CAL.
3. Continuing reduction in PPD may continue up to 12 months while in PMP.
4. Results were maintained for more than 36 months.
5. Furcations, maxillary bicuspids, and distals of second molars did not generally respond as well.
6. No antibiotics or other drugs were required to facilitate healing.
These observations are significant to p<.0001.11
The guidelines for site selection and sequence of perioscopy therapy within periodontal therapy are based on retrospective surgical candidate and prospective multicenter maintenance11 patient clinical trials.
Single rooted teeth respond well to perioscopy therapy. The response of pocket closure is predictable for these teeth if there is access for visualization and instrumentation. With most anterior teeth, this access is present with over-contoured restorations and root proximity as the major exceptions.
The data from retrospective studies and clinical experience reveal that molars with furcation involvement and maxillary bicuspids do not respond as well. There is a beneficial effect of perioscopy in these sites but the response is not as pronounced or as predictable as that observed around single rooted teeth. This lack of nearly complete resolution of pocket depth in furcation and maxillary first bicuspid sites is related to the clinician’s inability to thoroughly visualize and/or instrument these root surfaces.
The limitations of perioscopy in these sites may also be related in part to the current absence of effective scaling instruments for these sites. An example of a specific site that may respond unpredictably is the distal of second molars where access for vision and instrumentation is difficult because of root morphology, deep pocket depth, and firm, resilient gingival tissues. As some of these sites may not even respond predictably to surgical therapy, or the patient may not be a surgical candidate, the clinician may decide to perform perioscopy in these areas to gain some additional reduction in pocket depth and increased attachment level over that achievable by SRP and local delivery therapies.
The clinician will occasionally visualize root accretions that cannot be completely instrumented due to root morphology, inadequate access, or limitations of instruments available to the clinician for root preparation. These sites may respond more predictably to surgical intervention. Surgical access for debridement, pocket reduction, and regeneration procedures are appropriate where perioscopy cannot be performed.
Sequence of Appointments
Periodontal therapy begins with helping patients improve daily oral self-care and educating them about their specific disease processes. Education and oral selfcare instructions are provided at the first appointment and positive reinforcement/instruction continues at each subsequent appointment.
The dentist can use the endoscope as a diagnostic tool in selecting sites that may be treated with perioscopy and sites that may be more effectively treated with periodontal surgery. Reevaluating the root surface is mandatory after perioscopy if the pocket does not reduce significantly within 3 to 6 months. Additional perioscopy may be required if residual calculus is noted.
From Dimensions of Dental Hygiene. April / May 2003;1(2):12-13, 15-16.
1. Stambaugh RV, Myers GC, Watanabe J, Lass, C, Stambaugh KA. Visualization of subgingival root surfaces with the dental endoscope. J Dent Res. 2000;79(special issue):abstract 3656.
2. Stambaugh RV, Myers G, Ebling W, Beckman B, Stambaugh KA. Endoscope visualization of the subgingival dental sulcus and tooth root surface. J Periodontol. 2002;73:374-382.
3. Stambaugh RV, Myers GC, Watenabe J, Lass C, Stambaugh KA. Clinical response to scaling and root planing aided by the dental endoscope. J Dent Res. 2000;79(special issue):abstract 2762.
4. Nagy RJ, Otomo-Corgel J, Stambaugh RV. The effectiveness of scaling and root planing with curettes designed for deep calculus. J Periodontol. 1992;63:954-959.
5. Stambaugh RV, Dragoo M, Smith DM, Carasali L. The limits of subgingival scaling. Int J Periodontics Restorative Dent. 1981;1(5):31-41.
6. Kepic TJ, O’Leary TJ, Kafrawy AH. Total calculus removal: an attainable objective? J Periodontol. 1990;61:16-20.
7. Stambaugh RV, McMullin KA. Effectiveness of long term, non-surgical maintenance in deep periodontal pockets. J Dent Res (special issue). 1988;67:272.
8. Buchannan SA, Robertson PB. Calculus removal by scaling/root planning with and without surgical access. J Periodontol. 1987;58:159-163.
9. Fleischer HC, Mellonig JT, Brayer WK, Gray JL, Barnett JD. Scaling and root planing efficacy in multirooted teeth. J Periodontol. 1989;60:402-409.
Sherman PR, Hutchens LH, Jewson LG, Moriarty JM, Greco GW, McFall WT Jr. The effectiveness ofsubgingival scaling and root planing. I. Clinical detection of residual calculus. J Periodontol. 1990;61:3-8.
11. Stambaugh RV. A clinician’s three year experience with perioscopy. Compendium of Continuing Education in Dentistry. 2002;23:1061-1070.
Roger V. Stambaugh, DMD, MS, MSEd, FACD, specializes in periodontics and dental implants in his private practice in Burlington,Wash,and Santa Monica,Calif. He is also a member of Dentalview Inc’s Scientific Advisory Board.