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Perioscopy Information

Summary

This paper provides an overview of the Perioscopy technique and presents case studies demonstrating its successful use in hundreds of cases by Dr. Longbottom.

Current literature supports the use of powered instrumentation over traditional hand instrumentation. The objective of scaling and root planing is the complete removal of plaque, calculus and endotoxins from root surfaces. While complete removal is unrealistic, an accepted end result is a smooth, glassy root surface, but this often can result in excessive removal of cementum. This excessive removal of cementum during hand instrumentation is often because of lack of visualisation of the root surface.

Using endoscopic technology solves the visualisation problem making it easier to visually debride roots in a more conservative and minimally invasive way.

Perioscopic Endoscopy

The treatment of periodontal disease has always revolved around the effective debridement of the subgingival environment and the control of the microbial flora associated with the disease. Traditional non-surgical treatment can be successful but is limited by the lack of visualisation. Visual debridement has typically required surgical invention to reveal the root surface below the gumline.

Hand instruments used for debridement are limited in their access to the root surface because of their size and shape, especially with deeper periodontal pockets. The forces required to use hand instruments also increase risk of repetitive strain injuries in the clinician.

Powered instrumentation on the other hand allows treatment with less risk of repetitive stress injury and more predictable access to the entire root surface due to smaller instrumentation. The periodontal endoscope allows for visual access to root surfaces with greater magnification, lessening the need for surgical intervention.

Combined with a simple array of micro ultrasonic instruments, it’s possible to accomplish endoscopic debridement in a conservative, minimally intrusive way.

Micro Ultrasonics

This is a generic term that identifies the refined use of powered instrumentation used for high-powered, supragingival, gross debridement. Micro ultrasonic instrumentation is small, approximating the size of a periodontal probe and can be used for supra- and subgingival treatment at low to high power, with little or no water spray, and little or no adjunctive use of hand instrumentation.

Used appropriately, power-driven scalers may cause less root damage and /or excessive cementum removal than hand instruments. Complete removal of cementum in an attempt to eliminate endotoxin adherent to the root surface is unnecessary and may result in treatment complications such as hypersensitivity.

Power-driven instruments also provide better access to the base of the pocket and furcations. The objective is not the production of a smooth, glassy root surface but the adequate removal of plaque, calculus and its associated endotoxin such that the microenvironment permits periodontal healing. Using the ultrasonic scaler its possible to remove tenacious hard deposits with less patient and clinician discomfort and faster.

Periodontal Endoscopy

The periodontal endoscope allows for subgingival visualisation of the root surface at magnifications of 24x to 28x. This is accomplished through a very tiny fiber optic bundle containing camera and surrounding multiple illumination fibers. This fiber is delivered to the gingival margin along with an instrument called an “explorer”. A single-use sterile sheath isolates the fiber so it can be used repeatedly (70-80 uses per fiber).

The captured image is relayed to a screen so that the clinician can see “real-time” video of the highly magnified environment. (approx 3mm on screen at a time). A shielded version of the explorer is used for periodontal debridement and provides a mechanism for viewing subgingivally while “pushing” the soft tissue away from the camera lens, which is recessed, from the tip of the shield. There is an approximate 4mm space from the tip of the shield to the camera lens which allows for instrument to be placed within the viewing field for simultaneous viewing and instrumenting or “endoscopic debridement”. The explorers are angled to provide better access into various surfaces around the tooth.

The sheath is made of 2 tubes: one isolates the fiber and the other delivers water to the end of the fiber or camera lens. The both merge in a part of the sheath called the tip seal which fits into the explorer. Extending from the tip seal is a rigid metal tube with a very small sapphire lens.

Practice Protocols

Candidates for endoscopy include patients being treated for the following:

  • initial periodontal therapy;
  • sites that did not respond to traditional nonsurgical treatment;
  • residual pockets in patients who are resistant to surgical therapy and where surgery is contraindicated (medical reasons, or esthetics);
  • during maintenance for chronically inflamed or increasing pockets;
  • suspected subgingival pathology such as caries, root fractures, perforations or resorption;
  • and cases requiring documentation, such as for litigation.

Endoscopic instrumentation is a difficult task to master and a 2-handed technique works best. The endoscope is placed in the left hand and micro-sonic instruments in the right hand, thereby allowing viewing and instrumenting at the same time.

A 2 handed technique allows for viewing while instrumenting. Eventually, holding the endoscope in the non-dominant hand becomes second nature – very much like holding the dental mirror.

Endoscopic Treatment Options

Secondary use: Patients go through traditional tactile debridement followed by reevaluation; then sites that have not responded are endoscopically debrided
Primary use: Patients don’t go through a separate tactile debridement; they have initial endoscopic debridement followed by reevaluation.

Patient Introduction to endoscopy

All patients are educated on their diagnosis, the etiology of their problem, and given options. In the case of Periodontal disease, these options typically include:

  • doing nothing, which is not recommended for health of teeth and body
  • non surgical perioscopy treatment using the endoscope
  • surgical debridement
  • referral for second opinion

It is sometimes prudent to try tactile debridement first and then treat non-responding sites with perioscopy. Initially 90- to 120- minute appointments for pocketing in 1 to 2 quadrants are scheduled. Patients receive adequate topical and local anesthesia as this makes it easier to get the endoscope and mu instruments into the small subgingival environment without patient discomfort.

When Endoscopy is Difficult

  • In shallow pockets, the water that is not well contained does not allow for a clear flooding of the area between the tooth and the camera lens.
  • Very inflamed pockets and abscessed areas can have excessive bleeding and boggy soft tissue that can make visualisation difficult.
  • Distal furcations of maxillary molars tend to be in the middle third of the tooth and access may be more difficult for the instrumentation than for the endoscope.
  • Narrow furcations and class III furcations are difficult to visualize because the explorer will not fit into some of these areas because of size limitations.
  • Curved roots, root proximity and grossly over-contoured restorations create problems for the endoscope and instruments.
  • Limited jaw opening creates access problems for any type of instrumentation as well as the endoscope.
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