Endoscope Use in Daily Hygiene Practice










Minimally Invasive Periodontal Therapy: Clinical Techniques and Visualization Technology, First Edition.
Edited by Stephen K. Harrel and Thomas G. Wilson Jr.
© 2015 John Wiley & Sons, Inc. Published 2015 by John Wiley & Sons, Inc.
Companion Website: www.wiley.com/go/harrel/minimallyinvasive
55
4
The images in this section are to be used to provide orientation before accessing
the video link (available on the book companion website ). Figure4.1 shows the
clinical representation of how the endoscope shield is placed in the sulcus. The
remaining images are representative of the subgingival environment.
In the past, dental hygienists had traditional closed subgingival scaling and root
planing as the only option for treating periodontal disease. Technology brought
hygiene to the next level with the introduction of dental endoscopy over a decade
ago. It has become an invaluable tool for the hygienist in the treatment of
periodontal disease and peri-implantitis. The endoscope aids in diagnosis and
improves scaling outcomes. Learning to use the endoscope takes time; but with
patience and determination, hygienists will wonder how they practiced without it.
Advantages
The endoscope provides advantages for the patient as well as the hygienist. It
offers a way to remove calculus to a degree that prior to its introduction was
only possible with periodontal flap surgery. We are able to treat the disease early
and to obtain a more thorough, complete scaling in a closed environment often
saving the patient the pain and discomfort of a surgical procedure. Calculus is
often difficult to remove; therefore, visualization helps the clinician know when
Endoscope Use in Daily
Hygiene Practice
Kara Webb and Angela R. Anderson

56 Minimally Invasive Periodontal Therapy
the deposits have been completely removed without unnecessarily removing
additional tooth structure. For the first time, the endoscope allows the hygienist
to see how the instrument adapts to the tooth surface in the sulcus. Watching
this process as it happens allows the hygienist to see how to best adapt the
instrument around line angles, furcations, and other difficult areas to clean,
thereby helping to refine scaling techniques benefiting the hygienist when
working without the endoscope.
Learning curve
There are two aspects to the learning curve of using the endoscope. The first is rec-
ognizing what is in the field of vision (Figure4.2). Learning to identify the common
landmarks (the CEJ, furcations, restorative margins, etc.) and pathology (caries,
cracks, deposits, etc., Figures4.2, 4.3, 4.4, 4.5, 4.6, 4.7, and 4.8) happens in a short
time period. The second is learning to work with the instrument. There are two
different approaches for using instruments to remove subgingival deposits. One
approach places the endoscope into the sulcus for initial visualization to locate
and identify the type of deposit. The endoscope is removed and scaling takes
place. The endoscope is then placed back into the sulcus to view the tooth surface
and evaluate the efficacy of scaling. With this technique, it usually takes several
cycles to achieve the end result. A second approach, where there is adequate room,
uses both hands: one for the endoscope and the other for the scaling instruments.
This involves training the nondominant hand and has the longest learning curve.
Figure 4.1 Endoscope shown placed in the sulcus at the level of the CEJ.

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Minimally Invasive Periodontal Therapy: Clinical Techniques and Visualization Technology, First Edition. Edited by Stephen K. Harrel and Thomas G. Wilson Jr. © 2015 John Wiley & Sons, Inc. Published 2015 by John Wiley & Sons, Inc.Companion Website: www.wiley.com/go/harrel/minimallyinvasive554The images in this section are to be used to provide orientation before accessing the video link (available on the book companion website ). Figure4.1 shows the clinical representation of how the endoscope shield is placed in the sulcus. The remaining images are representative of the subgingival environment.In the past, dental hygienists had traditional closed subgingival scaling and root planing as the only option for treating periodontal disease. Technology brought hygiene to the next level with the introduction of dental endoscopy over a decade ago. It has become an invaluable tool for the hygienist in the treatment of periodontal disease and peri-implantitis. The endoscope aids in diagnosis and improves scaling outcomes. Learning to use the endoscope takes time; but with patience and determination, hygienists will wonder how they practiced without it.AdvantagesThe endoscope provides advantages for the patient as well as the hygienist. It offers a way to remove calculus to a degree that prior to its introduction was only possible with periodontal flap surgery. We are able to treat the disease early and to obtain a more thorough, complete scaling in a closed environment often saving the patient the pain and discomfort of a surgical procedure. Calculus is often difficult to remove; therefore, visualization helps the clinician know when Endoscope Use in Daily Hygiene PracticeKara Webb and Angela R. Anderson 56 Minimally Invasive Periodontal Therapythe deposits have been completely removed without unnecessarily removing additional tooth structure. For the first time, the endoscope allows the hygienist to see how the instrument adapts to the tooth surface in the sulcus. Watching this process as it happens allows the hygienist to see how to best adapt the instrument around line angles, furcations, and other difficult areas to clean, thereby helping to refine scaling techniques benefiting the hygienist when working without the endoscope.Learning curveThere are two aspects to the learning curve of using the endoscope. The first is rec-ognizing what is in the field of vision (Figure4.2). Learning to identify the common landmarks (the CEJ, furcations, restorative margins, etc.) and pathology (caries, cracks, deposits, etc., Figures4.2, 4.3, 4.4, 4.5, 4.6, 4.7, and 4.8) happens in a short time period. The second is learning to work with the instrument. There are two different approaches for using instruments to remove subgingival deposits. One approach places the endoscope into the sulcus for initial visualization to locate and identify the type of deposit. The endoscope is removed and scaling takes place. The endoscope is then placed back into the sulcus to view the tooth surface and evaluate the efficacy of scaling. With this technique, it usually takes several cycles to achieve the end result. A second approach, where there is adequate room, uses both hands: one for the endoscope and the other for the scaling instruments. This involves training the nondominant hand and has the longest learning curve.Figure 4.1 Endoscope shown placed in the sulcus at the level of the CEJ. Endoscope Use in Daily Hygiene Practice 57Figure 4.2 Endoscopic view of a healthy sulcus with enamel (E) and root surface (R) on the left and the endoscope shield on the right. Soft tissue (ST) is located between the tooth andthe endoscope and is pink in color, indicating health.Figure 4.3 Endoscopic view of the enamel (E) with caries (CA) and inflamed adjacent soft tissue (ST) on the left. The root surface (R) is also visible between the endoscope shield and theenamel. The endoscope shield is on the right. 58 Minimally Invasive Periodontal TherapyFigure 4.4 Root surface (R) of a tooth with a vertical fracture (F). The endoscope shield (S) is on the right. Soft tissue (ST) is in between the root and the shield.Figure 4.5 Black subgingival calculus (SC) which refracts yellow when viewed by the endoscope is present on the root surface (R). The endoscope shield is on the right. Soft tissue (ST) is in between the root and the shield. Endoscope Use in Daily Hygiene Practice 59Figure 4.6 Open margin (OM) between the porcelain crown (PC) and the root surface (R). The endoscope shield is on the right. Soft tissue (ST) is in the lower left of the image.Figure 4.7 Gutta percha (GP) is located in the furcation (F) of a mandibular molar. The gutta percha shows up light pink to beige on the bottom left of the image. The endoscope shield is on the right. 60 Minimally Invasive Periodontal TherapyAnesthetic-local versus subgingival topical anestheticThe discomfort level of the patient depends on the depth of the pocket and root sensitivity. In areas where the pocket is 5 mm or less and there is no dentinal sen-sitivity, topical anesthetics that can be applied directly into the sulcus work well. Local anesthesia is recommended in areas where the pocket depth is greater than 5 mm or the patient has thermal sensitivity.DiagnosticIn a dental practice, there are often situations where a patient presents with an infection around a tooth; and after clinical examination and radiographs, the cause of the infection is still undetermined. The dental endoscope can be used tovisualize the subgingival area to see if the cause is apparent. Root fractures, endodontic perforations, subgingival caries, root resorption, and crown margin discrepancies are some common issues (Figures4.2, 4.3, 4.4, 4.5, 4.6, 4.7, and 4.8).Increase in pocket probing depthTraditional scaling with hand instrumentation and power scalers often leave bur-nished deposits behind that continue to cause irritation to the soft tissue. Increase in pocket depth and bleeding on probing are primarily due to this residual Figure 4.8 Soft tissue (ST) fills the void created by resorption (RP). The endoscope shield is on the right. The root surface (R) is on the left. Endoscope Use in Daily Hygiene Practice 61subgingival calculus. Periodontal maintenance patients that have been stable but begin to show a localized increase in probing depth that remains after mainte-nance can benefit from this procedure.Chronic unacceptable probing depths are often found in areas of complex root anatomy such as developmental grooves, furcations, and enamel projections. When these anatomical features are present, it is often difficult to know when the area is free from deposits because the grooves become full and the calculus becomes smooth from repeated scaling. Working with the endoscope has proven that a smooth surface does not necessarily mean clean. The use of the endoscope gives the benefit of magnified sight in addition to tactile sensitivity.Traditional scalers and ultrasonics can be used with the endoscope. It can also be helpful to have additional instruments such as diamond-coated files, mini after fives scalers, files, and ultrathin piezo tips. Piezo scalers have more control options and thinner tips.ImplantsThe dental implant that has inflammation in the surrounding tissue and often an increase in pocket probing depth frequently has excess cement from the restor-ative process (Figure 4.9a and b). In the process of removal, the cement often breaks up into small pieces that become imbedded into the surrounding soft tissue. The endoscope allows the clinician to see where the cement is located and after scaling to see if there is any residual cement in the soft tissue that would need curettage.One approach suggests only using graphite or titanium instruments on implants, but cement by nature is tenacious and is not removed easily. Most often traditional instruments are needed to remove the cement. Cement is most often located around the collar of the implant; and therefore, scaling with traditional instruments does not damage the main body of the implant.LimitationsThe endoscope does not come without limitations. The clinician must consider root morphology and severity of inflammation. The complexity of multirooted teeth makes it difficult to see the entire root surface and access every curve and indentation. Roots can be close together creating a furcation that is narrow and inaccessible with the tip of the endoscope or scaling instrument.If the tissue has severe inflammation, it can completely block the view of the fiber-optic tip of the endoscope. The tissue folds around the shield, which holds the fiber optic, obstructing the view. Bleeding can also block the view of the tooth surface. When the disease is generalized, most clinicians experienced in endos-copy find it helpful to do closed subgingival scaling and root planing a few weeks prior to the use of the endoscope to minimize inflammation and bleeding, there-fore optimizing the field of vision. 62 Minimally Invasive Periodontal TherapyFigure 4.9 Implant (I) with residual cement (C). In (a), part of the implant can be seen betweenthe porcelain crown (PC) and the cement (C). Inflammation of the soft tissue (ST) isvisible on the bottom left of the image. In (b), the cement has been scaled and is no longer attached to the implant and has moved and is only visible on the upper right between the shieldand the implant. In both images, the endoscope shield is on the right.(a)(b) Endoscope Use in Daily Hygiene Practice 63ConclusionDental hygiene continues to make advancements toward treating periodontal disease. While the endoscope is not without challenges, it brings many advantages and improvements in the process of scaling and root planing. Hygienists could benefit in many ways by utilizing this technology in a practice setting.

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