Pocketful of Memories

Sept. 1, 2012
In past years, the advances in microscopic, minimally invasive surgery have helped calm those with anticipation tremors.

By Paul Feuerstein, DMD

In past years, the advances in microscopic, minimally invasive surgery have helped calm those with anticipation tremors. Arthroscopic procedures can be performed either to evaluate or treat many orthopedic conditions. This includes torn floating cartilage, torn surface cartilage, ACL reconstruction, and trimming damaged cartilage.

Believe it or not, these procedures date back to the 1920s. But it was not until flexible fiber optics were developed in the late 1970s that arthroscopy entered mainstream orthopedics. There are now many other medical procedures that can be performed with two or three tiny incisions, and with fiber-optic cameras and tiny surgical instruments. Large incisions are not necessary.

Since these processes are often used for removing structures that use indirect vision, you would think that there would be dental indications. Some TMJ surgery (still really an orthopedic joint procedure) is done with this technique. But think of one of the most common periodontal surgeries that are done — placing a flap to have visual access to subgingival calculus.

The operator debrides these areas by removing particles that were several millimeters inside of pockets. Even with fine instruments and excellent tactile expertise, these need to be opened and visualized. Of course, there are other aspects to this surgery, such as recontouring bony defects and repositioning flaps. But the initial therapy is often done after months or years of SRP with no great results. Areas of calculus elude even the most adept hygienists and dentists.

Can the arthroscopic technique be used here? There is already an opening (the sulcus) that can be accessed. So why not get a camera down there, along with some thin instruments, and clean the areas without the flap/incision?

Enter the perioscope. This device was developed over 10 years ago and introduced with little fanfare to dentistry. It was initially perceived as a large, expensive diagnostic tool that could see into the sulcus and visualize calculus.

While looking into the sulcus, other items were found. These included root fractures, the exact extent of furcation involvement, walls of bony defects, and caries. But this wonderful information was just that. Now what do we do with it?

Dr. John Y. Kwan, a periodontist in Oakland, Calif., saw this technology. He has been using the perioscope for minimally invasive, nonsurgical periodontal debridements for more than 10 years. The initial company, DentalView, was not doing well financially. So Dr. Kwan literally picked up the pieces. He formed a corporation, modified the water delivery system, manufactured accessories and consumables, and provided equipment service and training. His current protocol allows for removal of all calculus without surgery.

His team is working with a small array of magnetostrictive micro-ultrasonic inserts (0.5-mm diameter) to accomplish the root debridement without hand instruments. The perioscope camera probe is placed next to the micro-ultrasonic instrument so one can see what is being done on a screen.

The image is 20x to 40x — far beyond that of loupes and microscopes. Appointment times range from two hours for half- or full-mouth treatments, to longer, depending on the skills of the operator and the level of pocketing.

The process is much faster than surgical treatment, and the results have been remarkable. At this point, after having trained his hygienists, Dr. Kwan has delegated most of this treatment to the hygiene staff. This technique is easily accomplished without an assistant to make it suitable as a hygiene procedure.

The endoscope fiber is covered and protected by a sterile sheath that also conveys water to the camera end. This fiber/sheath complex is positioned around the teeth while placed into a set of four dental instruments called “explorers.”

Also, for more advanced processes, there are diamond-tipped ultrasonic inserts that can remove or reshape root irregularities, overhanging restorations, and even “sand” off shallow caries. At this time, Perioscopy Inc. is not manufacturing the DentalView unit. Dr. Kwan’s company will help with finding equipment, as well as upgrading, training, and providing accessories and consumables.

Dr. Kwan is passionate, and is leading the charge to put this more into the mainstream of periodontal therapy. Moving forward will require a new system. Development has recently started. Dr. Kwan’s website, with information and videos as well as postings on YouTube, is www.perioscopyinc.com. It is quite fascinating.

This is only the “tip” of things to come in this realm. As always, stay tuned.

Paul Feuerstein, DMD, installed one of dentistry’s first computers in 1978. For more than 20 years, he has taught technology courses. A general practitioner in North Billerica, Mass., since 1973, Dr. Feuerstein maintains a website (www.computersindentistry.com), and can be reached at [email protected].

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