Kristine A. Hodsdon, RDH, BS
Many elements are critical to the success of restorative and aesthetic dentistry. They include patient values and dental concerns, communication, complete diagnosis and treatment plans, color science, the relationship and harmony of hard and soft tissues, preparation design, provisionalization, laboratory fabrication, predelivery inspection, luting/cementation, material selection, and precise marginal adoption at the periodontal-restorative and tooth-restorative interfaces. But lack of visibility is one of several factors that can interfere with the achievement of a quality restoration.
Since the introduction of magnification, the evolution has moved rapidly through the dental community. Doctors are finding that magnification boosts the quality of their services; and some report that enhanced visualization has increased their speed. The underlying message is that they "can't prep a tooth without them!" Numerous articles and product reports highlight the benefits of incorporating this technology into restorative dentistry.
In addition to enhanced vision, properly selected telescopes allow doctorss to work with ergonomically correct posture, preventing or eliminating chronic neck strain.
In this article, I hope to provide a few strategies for incorporating magnification technology (intraoral-imaging cameras, loupes, and and endoscopy) into the hygiene department. Through this discussion, consider your answers to three questions:
- Can your hygienist distinguish between your marginal precision and nature's?
- Is the investment in hygiene magnification and illumination worth the benefits of further preserving your restorative artistry and improving the services provided by your hygiene team?
- Is it important for your hygientist to work with ergonomically correct posture, preventing or eliminating chronic neck and black pain?
All it takes is 90 seconds!
Performing a 90-second tour of the mouth with an intraoral camera during a hygiene visit can increase the patient discovery process and improve communication about periodontal and restorative possibilities. Many offices have talked about using an intraoral-imaging system and have even purchased a system only to leave it in the land of dust balls, dirty cloths, covered treadmills, rowing machines, and unused blood-pressure units.
The first goal is to have each hygiene room equipped with its own permanent intraoral camera (Vipercam, www.vipersoft.com; AcuCam Concept IV, www.gendexxray.com). Many doctors are kidding themselves if they think their hygiene team will get up, remove the personal protective equipment, wash their hands, track down the intraoral camera/cart, beg the assistant to let them take it from the doctor's operatory, push or pull it up and down the office's hallways, reposition the hygiene and patient chair (adjusting the various wires and tubing), drag the cart in front of the patient, plug the camera back in, redon the personal protective equipment, etc. If it is not a convenient and easy tool (camera handpiece, monitors conveniently located, camera networked with other computer systems), hourly usage will not happen. Do not blame the hygienists or the technology — instead, develop another plan for better implementation.
The next strategy would be to schedule a staff meeting or extended lunch hour to allow time for the hygienist to hold the camera, play with the foot pedal, try to take an image, and develop a clearer understanding of the "whys" and "hows" of incorporation. Lastly, for IOC integration, establish agreed-upon and written goals, expectations, and a timeframe for complete 100- percent-of-the-time intraoral camera usage. Foolishly, many offices operate under the assumption that after a one-hour "training" in a classroom on the use of the intraoral camera, all clinical team players automatically will be able to integrate the system seamlessly into their delivery of care. Creating a simple implementation strategy may decrease frustrations and increase long-term use and success.
Week One: Sally Flash (the team member who took to the intraoral camera like a bee to honey — the team member who "just gets it") will provide support for the hygiene department during the first month of incorporating the intraoral camera chairside. The hygiene department will use the intraoral camera on two morning patients and two afternoon patients. Prior to the doctor's exam, a single/four-plex intraoral image(s) will be displayed. Selection of which patients to use the intraoral camera on will occur during the team huddles.
Week Two: Hygiene department will use the intraoral camera on of the morning and afternoon patients. Prior to the doctor's exam, a single/four-plex intraoral image(s) will be displayed. Patient selection will be determined during the huddle.
Weeks Three and Four: Hygiene department will use the intraoral camera on all patients.
At the end of the first month, additional training should be scheduled and problems should be discussed.
Naked eye and beyond
The blending of where the natural tooth is and where the artistry of the definitive restoration begins is becoming virtually undetectable to the naked eye. Our patients favor that end-result, however many dental hygienists find it difficult, with unaided vision, to clinically differentiate the beginning and end-point of a margin, whether it's on a veneer, crown, direct composite, or even telling the difference between a rough or defective margin and calculus. Many doctors are aware that inadvertent, aggressive polishing and instrumentation may damage the margins and the effective surface texture of tooth-colored restorations. So, equip your "smile-preservation" specialist (hygienists) with loupe magnification and illumination (Orascoptic Telescopes, www.orascoptic.com; Designs for Vision, www.designs forvision.com; SurgiTel Telescopes, www.surgitel.com; Carl Zeiss, Inc., www.zeiss.com). Properly fitted loupes and adequate illumination are the keys to preventing costly clinical mistakes and providing ergonomic health for your hygienist. Many dental hygienists complete clinical assessments. Loupes can increase the hygienists' confidence levels, which may translate into more accurate data collection, evaluation, and restorative possibilities. Some services that may be performed more accurately and fine-tuned with proper magnification and illumination include:
Intraoral examination: Anatomical landmarks and abnormal lesions.
Hard-tissue examination: Occlusal analysis, aesthetic "upgrades," missing teeth, open contacts, defective restorations, fractures, staining at the restorative-tooth interface, abfractions/Class V noncaries lesions, detection of incipient and recurrent caries, advanced techniques for pit-and-fissure sealant placement, and fluoride varnish application.
Periodontal examination: Characteristics of the gingiva, improved ability to read the millimeter marking on the periodontal probe (at least without compromising posture), site-specific therapy diagnosis, and tooth/ restoration –gingival interface.
Radiographic examination: Comparison of radiographic series — detecting subtle, dimensional changes in bone, radiolucencies/radiopacities; outline of lesions; tabular pattern of the bone.
New depths in visualization
Some doctors are becoming increasingly sophisticated in their use of magnification technology. Another generation of magnification to assist the practitioner is the operating microscope [Telescopic Magnifiers, (800) 442-4020]. Reports state that this technology enhances a variety of restorative procedures by:
- Minimizing preparation irregularities
- Increasing the accuracy of impressions
- Improving marginal adaptation and aesthetics of provisionals
- Inspecting laboratory-fabrication procedures
- Assisting in marginal evaluation prior to restoration delivery
- Cleansing the preparation, confirming complete seating and controlling moisture (luting phases)
With advanced illumination and endoscopy (Dentalview, www.dentalview.com), hygienists can increase visual acuity during the delivery phase of periodontal therapy and local delivery of antimicrobial agents.
The operating microscope provides a view of the root surface and the pocket wall. In terms of assessing and measuring clinical-therapy outcomes, it is a tool of emerging importance. Evaluation can more easily take place with the ability to see deep into the treated or untreated pockets. Some areas that can now be visually accessed with the fiberoptic endoscope include subgingival calculus, furcations, root fractures, and subgingival caries.
Putting it all together
Precise restorative dentistry is essential for long-term functional and aesthetic success. Through magnification and illumination, precise delivery of hygiene services can be considerably improved. After the initial investment and short learning curve, a clinical hygienist can become familiar with using an intraoral camera, magnification loupes, and endoscopy, easily incorporating them into daily practice. After all, isn't your dentistry worth preserving?
Hints for magnification
Bigger is not always better: When purchasing loupes, a bigger image does not necessarily mean better clarity. The best loupes capitalize on the synergy of resolution and field width.
Superior visualization: Visualization of a loupe system must incorporate resolution, field width and field depth.
All systems are not created equal: Evaluate, sample, and compare all systems in order to choose a system that meets individual needs.
Advantages of using an intraoral camera
- Picture is worth a thousand words
- Image allows the patient to view the mouth from the practitioner's perspective
- Provides patient-controlled education outlet
- Increases case acceptance (restorative and periodontal) according to antidotal reports
- Provides record of the diagnosed area/treatment
- Before-and-after photos = great motivators and reinforcement
What defines quality loupes?
- Resolution: The capability to visualize small structures, set apart by the quality of the optical design and the use of precision lenses.
- Field Width: The size of the area being viewed through loupes.
- Field Depth: Range of focus delivered by the loupe (an average of four to five inches).
- Weight: The comfort of the complete frame and loupe system.
- Magnifying Power: The size of the image. Since there is no standard measurement for magnifying power in the loupe business, it really is only a rough guide when purchasing a system.
- Working Angle (angle of declination): Allows the user to work in a comfortable, ergonomically correct position.