Endoscopy

Endoscopy is a minimally invasive medical procedure allowing a physician to evaluate internal structures of the body through orifices or small surgical openings. Dental applications of endoscopy include visualization of the temporomandibular joint, maxillary sinus cavities, implant sites, endodontic evaluation of root canal areas, and to facilitate periodontal therapy. ^47-51 Dental endoscopes are designed to provide subgingival visualization and consist of a thin fiber-optic cable comprised of bundles of thin glass fibers that are less than 1 mm in diameter. Dental endoscopes utilize the fiber-optic cable to transmit light to and from the area to be viewed and the images are viewed on a display screen.⁵² When used subgingivally, the dental endoscope is used with internal irrigation and a sheath that provides a sterile barrier.⁵² The dental endoscope provides magnification from 24-48x and is used with specialized probes, curettes, and retracting instruments to maximize visualization. The endoscope allows for real-time subgingival imaging with illumination and magnification.⁵² While further long-term controlled studies are required, it should be noted that histologic evidence of chronic inflammation and microscopic calculus root accretions were not found and/or were minimal at 6 months after ScRP with the use of the periodontal endoscope, which may indicate long-term benefits and/or a decreased likelihood for disease recurrence after the use of this visualization technology.⁵³

Figure 2: Visualization of subgingival calculus can be achieved with the periodontal endoscope.

Various randomized controlled studies have been performed to evaluate the use of the periodontal endoscope.^51-61 A recent systematic review and meta-analysis evaluating these reports concluded that the use of the periodontal endoscope could improve subgingival calculus removal when compared with ScRP alone.⁵² However, clinical outcomes after ScRP with the use of a periodontal endoscope, including bleeding on probing (BOP), gingival index (GI), and probing depths (PD), did not demonstrate a statistically significant difference when compared to ScRP alone.⁵² One explanation for these findings may be the relatively challenging and novel skills associated with use of the periodontal endoscope, including ambidextrous use of instrumentation, and the potential for a steep learning curve when adopting such a technology.⁶² It has been suggested that a 2-4 week training period is necessary for mastery of the skills required to proficiently operate the periodontal endoscope.⁶³Additionally, operator experience may influence the advantage provided by the use of periodontal endoscopy; in one preclinical investigation, no statistically significant difference was seen in simulated root surface deposit removal due to operator experience whereas operator experience did result in increased deposit removal without endoscope use.⁶⁴ There may also be anatomical limitations to the efficacy of a periodontal endoscope in clinical practice. Overall residual calculus deposits were improved with periodontal endoscope use on single-rooted teeth, but not at multi-rooted teeth, which may suggest that root flutes and the complex anatomy associated with furcations may limit the effectiveness of adjunctive endoscopy use.^51,52,55 Lastly, the use of the periodontal endoscope is associated with an increase in treatment time and should be considered as a practical aspect of the clinical use of the periodontal endoscope.^51,55,63,64 For example, more time may need to be allotted to ScRP procedures when periodontal endoscopy is used as an adjunct and this may not align with remuneration associated with most fee schedules. There are no Current Dental Terminology (CDT) codes at this time that are associated with the adjunctive use of periodontal endoscopy during nonsurgical periodontal therapy,⁶⁵ which could also limit widespread adoption and no data currently exist on patient-centered outcomes and assessment of post-procedural comfort associated with the use of adjunctive periodontal endoscopy for visualization during ScRP. In many practices, a cost-utility analysis regarding the additional benefits that may be conferred with use of periodontal endoscopy weighed against the costs of increased instrumentation and upkeep and the time and training of dental healthcare professionals for the effective use of periodontal endoscopy.