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07/02/14

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07021407/02/14

My First Steps into Hi Res Dentistry

I have been practicing general dentistry for nearly 15 years having qualified from the London Hospital in 1998. I run a busy 4 surgery private practice in Spalding Lincolnshire. I starting using loupes about 4-5 years after qualifying and soon found them indispensible, initially using 2.7x Galilean oculars but then moving to 3.5x Prismatics, these conveniently also incorporate a protective filter for use with my diode lasers. Whist I found the magnification adequate for most procedures the ergonomics of loupes at the higher magnification levels was less satisfactory. The loupes were heavy and dug into my nose and ears, the depth of focus was very narrow requiring one to sit very still with resultant muscle stiffness and aches and being tied to my light box behind was a pain. I have never liked the bluish light from the head mounted LED’s on most loupes.

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I first became aware of microscopes during discussions with another delegate on and endo course, he was so enthusiastic about all the new stuff he could see that I made a mental note to investigate further. After quite considerable research over a couple of years I came to conclude that the Opmi Pico from Zeiss offered the best ergonomics, durability and performance needed for my busy practice. The Pico system all offered two distinct advantages over any of the other offerings. Firstly a very clever swing mechanism (Mora Interface) that allows scanning from one side of the mouth to the other with the lightest touch of a finger, with no movement of the eyepieces. Secondly a highly adjustable primary objective lens system called a varioscope, this allows a huge range of focus adjustment making patient positioning very easy, basically chair back, set magnification, quick tweak of the varioscope dial and hey presto, crystal clear super size, super bright teeth!

It was then at the BDSA dental showcase and later at another Endodontic conference that I came across Steve Clapman from Nuview. Nuview are the UK distributor for Zeiss microscopes. Steve’s knowledge and enthusiasm for his subject was very apparent from the start. He arranged to come and do a site visit to discuss my potential options. I was impressed with Steve’s professionalism at this visit as he guided me through the myriad of options available carefully crafting a system that would fulfil my needs and fit into my surgery and likely workflow as seamlessly as possible. I was impressed and surprised that he actually guided me away from a couple of more expensive components that he thought did not offer good value for my needs which now, in more experienced hindsight, I would certainly agree.

Having placed my order, I had to wait a slightly frustrating 6-8 weeks for delivery as all Zeiss scopes are custom built to each customers individual specification. During this time Nuview kindly organised for me to attend the annual Zeiss symposium conveniently held in London last year. This was an excellent 2 day meeting with many international speakers all very keen to share the experiences in the use of microscopes in many areas of dentistry. There were also several hands on sessions where various, surprisingly easy, microsurgical techniques were demonstrated and opportunity made to try out. The symposium was also an opportunity to meet the rest of the Nuview team who were exhibiting and also helping host the weekend, all very knowledgeable, friendly and keen to answer my long list of questions.

Steve delivered the scope in person and spent a day fitting and setting it up. He then spent several hours getting me setup, instructing me on good posture and familiarising me with the various controls. Fortunately these were all very intuitive and I was soon excited to get going.

Having made a fairly considerable investment in the scope I was determined to use it for as much as possible and not have it collecting dust only to be brought down for the occasional tricky endo or crown prep. With this in mind I got stuck in straight away the next day with a busy morning of checkups, whilst looking ‘forward’ and working ‘down’ was a little alien to start with the advantages were immediately obvious. The huge degree of detail makes checkups frankly easy. Even using comparatively low 4-6x magnification the fabulous axial illumination shows the slightest differences in enamel translucency easily showing early subsurface demineralisation and caries, even interproximally. Filling defects, failing crown margins and fine cracks literally jump out at you. The graduations on the perio probe are easily readable at a glance. Subtle differences in the colour and texture of the soft tissues make the soft tissue exam quicker and easier. Documentation is also so much easier, anything of interest is quickly snapped with the attached SLR and demonstrated to the patient moments later and then filed away in the notes for later reference, or printed to accompany a referral. I have used various intraoral/extraoral cameras in the past but always found lens steaming and smearing and grainy images to be a real pain. No such issues with the scope.

The improvement in posture was immediate and noticeable; feeling the back rest of your stool consistently pushed into your lower back is a very refreshing change not to mention the absence of neck ache at the end of the day. Being comfortable just seems to remove a lot of the drudge of a busy day. I would highly recommend the addition of a Support Stool with separate articulated armrests from BQE, solid 9-10hour days no problem!

After 2-3days of scope driven checkups we moved to simple treatments, some descaling and fissure sealants etc. Using the scope at the lower end of the scale around 4x is really quite easy as generally the whole mouth is visible and the appearance very similar to medium powered loupes. Finding the mouth with instruments takes a little practise initially. I have found a sweep in with hands close under the scope, until they come into view, and then a drop down into the mouth works well and avoids ending up with a mirror handle up a nose or stuck in an ear.

Confidence to take a headpiece to a tooth under scoped vision took a little longer, around 7-10days, though once completed many advantages again became clear. You can just see, EXACTLY, what you are doing. Once you are in place burr beside tooth, usually using 6-10x magnification, your mind focuses in on the task in hand and you soon forget about the decreased field size. Old restoration removal is quicker as you can easily see when filling ends and tooth begins even with well colour matched composites. The fine differences in texture/translucency between carious and sound dentine is much more apparent immediately reducing the need for time consuming double checking with a probe. Iatrogenic damage to adjacent teeth is easily avoided as the adjacent marginal ridge appears like a cliff face next to your class 2 preparation. You do however notice a lot more rough margins and early signs of recurrent caries on adjacent teeth. Fortunately the greatly increased vision makes simple repairs or refinishing of such restorations much easier. Cracks lurking under old restorations are also quickly identified, documented and reported to the patient with a clear picture. Preps can then easily be modified to allow cuspal coverage of weakened areas or a move straight onto full coverage crown preparation if time allows. Confidence to regularly use the scope to complete full crown preps has taken about 2-3months but once you have half a dozen under your belt you soon start to miss the pavement wide appearance of your margins at 10-16x magnification. I predominantly use the CEREC CadCam technique for individual crown restorations. Whilst the marginal adaptation of CEREC is potentially excellent it can be quite fussy about smooth flowing margins making loupes at the least essential, the scope again makes these easy. Assessment of line angles/parallelism and undercuts is also a doddle with the scope due the excellent axial lighting and directly vertical orientation of one’s vision especially if one eye is briefly closed.

Endodontic procedures have always been the regularly quoted ‘bread and butter’ use for dental microscopes. I can now certainly see why. I have always had quite an interest in endodontics especially since starting to use loupes and rubber dam routinely. I have always strived to find the MB2 in upper molars and guess I found them 20-30% of the time with loupes. With the scope this has immediately increased to what seems more often than not. The differences between the translucency of primary and secondary dentine is so much more apparent under good lighting and higher magnification. Even with highly sclerosed canals it is possible to carefully follow the darker secondary dentine with ultrasonic instruments usually dropping into the canal a few mm’s further down. With this increased confidence I have been able to revisit a few of my past problem teeth, most notable a troublesome upper premolar that never quite settled down when first treated 2 years ago. Radiographically the finished endo looked lovely, painstakingly repeating the procedure still did not give resolution. Finally repeating the RCT for 3rd time, but this time using the scope revealed a small blob of gutta percha adhered to the buccal canal wall after removal of the old filling. Further investigation under 16 x magnifications finally showed a branching second mesio-buccal canal, pre-curving of some more files then quickly navigated this extra canal. After thorough cleaning and obturation all symptoms resolved in a week, happy days! All without having to go on any extra fancy courses or buy new fangled file systems, just by being able to properly see what you are doing. This really does apply to all areas of restorative technique, if it’s easy to see, it so much easier to do and do well.

Higher magnification does of course always come with the disadvantage of decreased field of view. At 4x you can see the whole mouth, 6x a quadrant, 10x 2-3teeth, 16x a single tooth, 20x a single canal orifice. Six times magnification is plenty for most single tooth restorations and gives a field of view similar to what would usually be isolated if using dental dam. Whilst I routinely use dam for all endo procedures I do not generally find it necessary for simpler restorative techniques using the scope.

I have now been using the scope for 4 months and already find it an indispensible part of my day to day practice. I honestly use it 75% of the time, obviously it’s little use in more ‘macro’ procedures like denture prosthetics or general extractions and I always prefer to down tools and sit in front of patients to discuss treatment plans and the ’bigger picture’. I would be lying if I said it did not slow me down a bit for the first few weeks but the many advantages quickly start to give genuine time savings and I am now back to 95% of my original throughput but with considerable improvements in treatment quality and consistency of outcomes. Patients have been very enthusiastic and interested in this very obvious addition to the surgery, most commenting they’ve never seen anything like it elsewhere, which must help with their perceived value in our service.

As vision magnification with loupes has become very common place over the last 10 years I suspect there will be a similar progression into the use of scopes especially with students being exposed to their use and benefits within their undergraduate teaching. I would thoroughly recommend anyone who enjoys taking pride in their work to have a go, yes a bit of early perseverance is needed but I have found it a lot easier than I would have expected, and would now be very reticent to work without out. The initial cost may also seem a bit prohibitive but as it has few moving parts I cannot see why it should not last potentially for the rest of one’s career, maybe with the odd light box upgrade or occasional service. It was for this reason also that I decided to go with Nuview and Zeiss. As your first pound is always your best pound I just thought it was sensible to get the proper job right from the start also making transition into this new world of fabulous high resolution dentistry so much easier as well. The improved ergonomics also make it a great investment in one’s self, it will undoubtedly help my neck and back make it to a comfortable retirement, and anything that saves down time with back issues will pay for itself very quickly.

I would be more than happy to discuss any aspects of integrating a scope into your daily practice and am easily contactable at jimonline99@hotmail.com, Though a quick call to any of the excellent team at Nuview will soon have you on the path to much more fulfilling and comfortable career.

Dr James Shorrock BDS