Periodontal Instrumentation Transformed

Periodontal instrumentation is often a frustrating experience. How many times have you scaled a deep pocket or furcation and wished you could see the deposits on the root surface down to the base of the pocket? Our tactile senses are often inadequate when dealing with blood, saliva, and difficult access in these problem areas. As a result, even our best efforts frequently fall short.
Periodontal surgery can allow better access and direct visualization. Despite referral to the periodontist and repeated recommendations for pocket elimination surgery, there are thousands of patients who do not receive surgical treatment for economic and medical reasons.

The Dental Endoscope

The dental endoscope has opened a new era in nonsurgical periodontal therapy. Perioscopy combines the words periodontal and endoscope to describe the use of the dental endoscope in periodontal diagnosis and therapy. Using this miniature television camera that incorporates intense fiberoptic light and 24x-48x magnification, we are now able to achieve more thorough periodontal debridement than ever before (Figure 1). Finally, after all these years, as the traditional hymn states,”I once was blind, but now I see.

“Since the introduction of this new technology, we are among approximately 15 clinicians who have had more than 3 years of extensive clinical experience with endoscopic subgingival instrumentation. Currently,there are more than 300 dental endoscopes in use in the United States. Our experience has revealed the answers to many questions regarding the nature of deposits,the effects of various instruments, and the ultimate end point of instrumentation.

Because this technology is new, few clinicians have used this equipment and studied its effects on therapy. Controlled clinical trials and more published research are necessary. Endoscopic studies are now in progress. Until these are completed, we can only report our observations, recognizing that they are not evidence-based facts. However, the endoscopic images we have seen are so compelling, and the clinical results,^2-4 are so apparent that clinicians and educators may need to reevaluate and revise their concepts regarding instrumentation.

Figure 1. Subgingival instrumentation with curet and dental endoscope in a periodontal pocket.	Figure 2. Dental endoscope viewing a furcation.

Illustrations courtesy of DentalView Inc

A Shift in Education and Care

Evidence in the periodontal literature has been cited as proof that thorough removal of calculus is not possible and that residual calculus may not be important.^5,6 Literature has shown that clinicians virtually always leave calculus after subgingival instrumentation.^7-9 Despite the fact that deposits are left, scaling and root planing result in reduction of pocket depth and inflammation, and a gain in clinical attachment levels.^10-12 From this evidence, some have concluded that it is not important to remove all calculus and instead focus their instrumentation efforts on removing loosely adherent subgingival plaque and endotoxin. According to this philosophy, calculus can remain, as long as there appears to be an acceptable reduction in inflammation. This is referred to as a “major paradigm shift “in dental hygiene education and practice.

In some dental and dental hygiene programs, this concept has resulted in less emphasis on thorough subgingival root instrumentation and greater emphasis on subgingival plaque debridement with low-powered thin ultrasonic tips. We believe that this approach fosters and condones incomplete instrumentation.

Although leaving some calculus may be compatible with successful periodontal treatment, the experimental literature has never defined how much calculus can be left. The literature offers little guidance on how much instrumentation is enough for any individual patient. Until this is answered by future clinical studies,it remains an open question. We would caution clinicians not to interpret the literature to mean that less than thorough instrumentation is acceptable. Observations with the endoscope lead us to believe that complete deposit removal, or something very close to it, is necessary for resolution of inflammation and long-term maintenance of periodontal health.

Clinical Observations

Our clinical experience with the endoscope over the past 3 years has led to the following observations:

1.Burnished calculus deposits are always present following both manual and/or ultrasonic instrumentation.

Even very experienced clinicians are deceived by the tactilely smooth surfaces achieved by ultrasonic instrumentation and they assume that the root surfaces are free of deposits. However, endoscopic evaluation of surfaces scaled with various ultrasonic tips, especially under low power, has consistently revealed burnished calculus, ranging in size from large, smooth, flat sheets to small, flat “islands.” These residual deposits are usually located in furcations (Figure 2), developmental depressions, at line angles, and around the cemento-enamel junction.

Although this seems to suggest a condemnation of ultrasonic instrumentation, we have also observed that experienced clinicians using manual instruments also leave some residual burnished subgingival deposits.

2.Clinicians experienced with manual or ultrasonic instrumentation can produce equal finished products. At best, both methods, alone or in combination, always leave small amounts of burnished deposits.

3.Residual burnished calculus provokes inflammation and bleeding in the adjacent soft tissue (Figure 4).Endoscopic examination consistently shows that at a 4 week re-evaluation whenever even the smallest speck of calculus (0.5 mm in diameter or less) is seen on the tooth surface, there is a corresponding inflamed, bleeding ulceration in the pocket lining exactly opposite that piece of calculus (Figure 3).

Even if instrumentation is able to reduce the amount of plaque and endotoxin on the root surface for a while, the burnished calculus either is recolonized by the bacteria quite rapidly or it harbors residual viable bacteria, endotoxin,or other antigens that are sufficient to cause continued bleeding in the adjacent tissue. This bleeding can only be seen if the piece of calculus is large or close to the gingival margin. Small, burnished deposits located near the base of deep pockets will cause bleeding that is delayed due to the time it takes for that small amount of bleeding to reach the gingival margin.

4. Endoscopic examination reveals residual burnished calculus in 100% of pockets and furcations that bleed upon probing.Numerous clinicians experienced in perioscopy agree that whenever bleeding on probing is seen, residual, burnished calculus and/or irregular restorative margins are seen with the endoscope.

5. Endoscopic evidence of bleeding of the pocket wall and bleeding upon probing are clinical signs that future loss of attachment may occur. Although bleeding on probing does not always mean that attachment loss will occur,¹³ a study by Lang et al found that 30% of sites that exhibited bleeding at four out of four preceding recalls lost attachment.¹⁴ Since we cannot predict which sites will break down, elimination of bleeding should be a goal of therapy.

6. If all calculus and plaque are removed from the root surface with the aid of perioscopy, elimination of bleeding upon probing and closure of the pocket by formation of a long junctional epithelium is more likely to occur. Data are now being collected by Stambaugh and coworkers to determine how many pockets treated to a level of Subgingival Calculus Index O (SCI O) have closed resulting in a shallower depth.¹⁵

Perioscopy is a diagnostic viewing procedure that is only as effective as the instrumentation the clinician is able to perform. In other words, if you can get the root extraordinarily clean, it will heal extraordinarily well.

7. For many years, expert clinicians have been able to achieve closure of pockets by formation of a long junctional epithelium following skilled root instrumentation. Did master clinicians like Hirschfeld and Gracey realize this decades ago? It is possible that what we are now able to consistently achieve with the aid of the endoscope is exactly what these experts were able to achieve through meticulous instrumentation.

8. Ultrasonic and manual instrumentation require roughly the same time to achieve the same result.

The perception that ultrasonic scaling is faster than manual scaling is based on the assumption that the end product—a smoother root surface—is free of deposits. In fact, perioscopy has shown that moderate to heavy deposits are often merely burnished so they become difficult to detect with explorers or probes. Sheets of highly burnished calculus are always present after ultrasonic scaling unless the clinician uses heavier ultrasonic tips at higher power settings over a considerable amount of time. Tenacious calculus removal is a tedious, time consuming procedure regardless of the ultrasonic device or tip employed.

Tenacious calculus removal requires an extraordinary number of strokes and a prolonged amount of direct contact time on the deposit with the ultrasonic tip at medium power or higher. This time is approximately the same or can be longer than that needed for careful manual instrumentation. The advantage of ultrasonic instrumentation is that less lateral pressure is required and sharpening is not necessary.

9. The assumption that “smooth” is “clean” is not necessarily true. Smooth surfaces are more likely to be deposit free but smoothness is not a guarantee of cleanliness.

10. Perioscopy facilitates complete removal of calculus without excessive removal of tooth structure. This is possible because the clinician is not working blindly, relying only on tactile sensitivity. Very precise instrumentation is accomplished by first viewing, scaling the isolated deposit, and then viewing the root again.
This “view, instrument, view” process is repeated until a clean root surface is achieved without disturbing the surrounding tooth structure. Simultaneous viewing and scaling are difficult because the pocket space is too narrow to allow instrumentation while the endoscope is in place. Current instruments need to be miniaturized to facilitate perioscopy.

11. Water irrigation associated with perioscopy may help reduce inflammation. During perioscopy, constant water irrigation clears blood and debris from the pocket. Free-floating pathogens, loosened biofilm, and calculus are flushed out while sites are viewed. This extended irrigation time (10-30 minutes per site) results in much more irrigation than is associated with ultrasonic scaling or manual postscaling irrigation.

Further research is necessary to determine how much of the positive tissue response to perioscopy is due to the instrumentation and how much is due to the water irrigation. Whether this irrigation effect is clinically significant is not yet known.

12. Endoscopy reveals small deposits that cannot be seen during periodontal surgery even with surgical microscopes or loupes. Some clinicians assert that the use of the endoscope is not necessary because subgingival deposits can be viewed during periodontal surgery. However, these deposits are often so minute that they cannot be seen during surgery.
Surgical microscopes have a resolution of 8x-24x with a very shallow depth of field. Even the slightest movement by the patient will make the image go out of focus. The endoscope allows viewing with intense illumination at 24x-48x of root surfaces, the inner aspects of furcations, and bony defects that cannot be seen with any other device .

Figure 3. An endoscopic view of residual burnished calculus.	Figure 4. Viewing subgingival calculus in a severely inflamed pocket.

 

13. Endoscopic instrumentation does not totally eliminate the need for periodontal surgery. Perioscopy is effective in anterior teeth and in posterior pockets that are accessible. It is difficult at the base of deep narrow infrabony pockets, areas of close root proximity, curved roots, overhanging restorations, and on the distal surfaces of maxillary second and third molar teeth. Surgery enhances access in these difficult areas.

Even in these areas, however, perioscopy can be an important surgical adjunct. Its use can provide a cleaner root surface and this may be critical to success in periodontal regeneration procedures. Perioscopy may someday lead to less invasive periodontal surgery just as it has in medicine.

14. No accurate, objective assessment of instrumentation can be made without thorough endoscopic examination. We believe that endoscopy assisted periodontal instrumentation will improve the standard of care in the future. When we evaluate scaling and root planing with only tactile means or by subsequently examining for bleeding and inflammation, we are working “blindly” and often guessing. Perioscopy allows a direct view inside periodontal pockets so that more accurate diagnosis and treatment can be rendered.

15. For the first time in history, tactilely undetectable deposits can be seen and completely removed during a nonsurgical procedure. Complete removal of calculus and associated plaque biofilm from the root surface results in extraordinarily good healing. Often there is elimination of inflammation and bleeding, as well as pocket depth reduction, and a gain in clinical attachment when endoscopy assisted instrumentation has created “perioscopy clean” roots.^1,4

Recognizing that this discussion falls outside the bounds of evidence-based clinical trial research, the observations of the past 3 years are presented to stimulate further study. Clinicians who have delivered nonsurgical periodontal therapy with the aid of the dental endoscope report dramatic healing following their efforts. Clinical trials are needed to assess objectively the response to this new form of therapy. The frequency and longevity of these clinical improvements must be documented. Clearly, perioscopy appears to hold great potential to enhance therapy outcomes and benefit patients.

References

1. 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.
2. 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.
3. Stambaugh RV, Myers GC, Watanabe 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. Stambaugh RV. A clinician’s three year experience with perioscopy. Compendium of Continuing Education in Dentistry. 2002;23:1061-1070.
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9. Sherman PR, Hutchens LH, Jewson LG, Moriarty JM, Greco GW, McFall WT Jr. The effectiveness of subgingival scaling and root planing. I. Clinical detection of residual calculus. J Periodontol. 1990;61:3-8.
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12. Badersten A, Nilveus R, Egelberg J. Effect of nonsurgical periodontal therapy (VIII). Probing attachment changes related to clinical characteristics. J Clin Periodontal. 1987:14:425-432.
13. Claffey N, Egelberg J. Clinical indicators of probing attachment loss following initial periodontal treatment in advanced periodontitis patients. J Clin Periodontol. 1995;22(9):690-696.
14. Lang NP, Joss A, Orsanic T, Gusberti FA, Siegrist BE. Bleeding on probing. A predictor for the progression of periodontal disease? J Clin Periodontol. 1986;13(6):590-596.
15. Stambaugh RV. Perioscopy—the new paradigm. Dimensions of Dental Hygiene. 2003;2:12-15.