Enhanced Visualization Technologies

Periodontal therapy aims to restore the periodontium to a state that allows for maintenance in health without clinical signs of inflammation or disease progression and to reestablish comfort, function, and esthetics.²⁰ Nonsurgical therapy includes the control of both primary and secondary etiologic factors. The removal of dysbiotic plaque biofilm, bacterial byproducts as well as plaque-retentive materials such as calculus, are critical to this treatment, paired with strategies to address secondary etiologic factors including systemic disease control, tobacco cessation/reduction, management of occlusal dysfunction, etc.^4-9 Scaling and root planing (ScRP) is a fundamental treatment for periodontitis.^10-13The primary objective of ScRP is to restore periodontal health through removal of pathogenic products from periodontally-involved root surfaces to create biologically acceptable root surfaces.^10-13These products, including plaque biofilm, calculus, and endotoxin, serve to induce host response and inflammation leading to attachment loss.²¹When performed adequately, ScRP results in significant reduction in probing depths, bleeding on probing, and subgingival dysbiotic biofilms, but limitations to ScRP efficacy exist.¹³It has also been noted that as calculus is a reservoir for live pathogens and bacterial endotoxins and thus incomplete calculus removal is associated with reinfection of the local subgingival environment and induce a recurrence of periodontitis.^14,15Despite its widespread use as initial therapy for periodontitis, ScRP has rarely been found to achieve total calculus removal.¹⁶Furthermore, decreased effectiveness of ScRP has been associated with increased pocket depth, lack of visualization to access and identify residual deposits, instrumentation used, and operator experience.^16-19Surgical access to allow for increased visualization has been shown to improve the efficiency of removal of deposits, but there are challenges and limitations to surgical therapy, including patient acceptance and potential post-operative esthetic compromise, patient discomfort, and healing times.^20-23To increase the effectiveness of nonsurgical therapy, the use of enhanced visualization techniques, including the use of magnification loupes, periodontal endoscope, and microscopy have been proposed to enhance visualization and combat operator fatigue.

While the use of magnification in dentistry has occurred over the last few decades, the history of magnification stretches far back into history. It has long been proposed that magnification enjoyed widespread use throughout antiquity. The so-called Nimrud lens is a rock crystal artifact dated to the 7th century BC which may or may not have been used as a magnifying glass, or a burning glass.²⁴ It is also believed that the first known description of magnification is that of simple glass meniscus lenses described in hieroglyphics Egypt over 2800 years ago.²⁵Furthermore, dental plaque observed under a microscope by Anton van Leeuwenhook in 1694 established the basis for microbiology.²⁶ The “animalcules” that van Leeuwenhook observed are also the primary etiological agents against which our current periodontal therapies are aimed. It is fitting, then, that current trends in periodontal diagnosis and treatment are incorporating these magnification techniques into more common use.

Figure 1: Galilean v. Keplerian (prismatic) lens design. Magnification loupes may be of either Galilean or Keplerian design.