Visual (career) enhancement

Feb. 1, 2013
Imagine that you could look directly at a root surface, 6 or even 12 mm down inside a pocket, while you're working. Would that make your job easier?

Hygienists describe the benefits of working with dental endoscopes

by Cathy Hester Seckman, RDH

Imagine that you could look directly at a root surface, 6 or even 12 mm down inside a pocket, while you're working. Would that make your job easier? How much would you (or your employer) be willing to invest in training and technology to have that capability?

Peggy Chesser, RDH, BS, of Henderson, Nev., works in general dental offices as an independent consultant using a Perioscopy to perform meticulous, direct-view scaling and root planing. Lynn Groff, RDH, owns a similar business in California and travels to periodontal offices as a consultant. Nancy Kiehl, RDH, MS, works for two Ohio periodontists using dental endoscopes. Suzanne Newkirk of Georgia works with a periodontist part time in Washington state, and is a Perioscopy instructor.

First, some definitions and background. An endoscope is a medical imaging device that provides a view inside the human body. A dental endoscope is a specialized endoscope that uses a miniature camera to look into periodontal pockets. Dental endoscopes got their start, according to Chesser, in 2001 with a company called Dental View. A few hundred were sold, but there were design flaws. The major flaw, Chesser says, was that the method used for water delivery was not conducive to good vision. Many of those original dental endoscope were moved to a back corner and never used because of the difficulty with vision.

When the company failed in the mid-2000s, periodontist John Kwan of Berkeley, Calif., purchased the rights to the technology and founded Perioscopy Inc. (www.perioscopyinc.com). Kwan's company installed an external water supply for the Perioscope, and changed the explorers that hold the fiber optic camera. A new model is due out this year, Chesser said, which has better imaging capability and touch-screen image capturing.

Chesser first became aware of the possibilities of dental endoscopy when the periodontists she worked with decided to dust off their unused Perioscope and send their hygienists for one-on-one training with Dr. Kwan and his hygienist, Chris Wood.

"We were blown away," she says of that training. "He could do full-mouth endoscopic debridement meticulously, and we could see everything exactly. It was one of those light bulb moments, the most exciting in my 32 years of dentistry. The light bulb turned on; that's what that moment was for me. We came back to our office thoroughly excited about the technology. I won't say there wasn't a lot of blood, sweat, and tears. It's a most challenging skill to learn, and basically, I taught myself."

In the beginning, she said it took two hours to scale one tooth, but the periodontists were supportive, and allowed as much time as was needed until the hygienists mastered the instrument. Hygiene revenues went up massively, Chesser said, and the periodontists were able to spend less time on flap surgeries and more time on implants, grafts, and other things.

"It's such a rewarding skill," Chesser says. "It's what every hygienist went to school to do, isn't it? To clean teeth? Without an endoscope, you don't know what you're leaving. Even if the root feels glassy smooth, there can be burnished calculus. When you can see what that looks like, magnified 48 times, it's just a marvel. That's how my journey got started."

The beginning of Chesser's hygiene journey was at Ohio State University where she earned a bachelor's degree in 1980.

"I grew up on a farm in Coldwater, Ohio, and never had good dental care. My mouth was a nightmare, and our local dentist offered to trade dental treatment if I worked for him as an assistant. I went back to Coldwater after graduation, but eventually moved to Dayton and married an Air Force pilot."

The couple raised two sons at postings all over the west.

After her husband retired from the Air Force, they settled in Las Vegas, but divorced in 2000. "Dental hygiene," she says, "gave me the opportunity to raise my boys and send them to college." Drew, 26, is a student at Emory Law, and Brendan, 24, has just graduated from the University of Nevada Las Vegas with a degree in kinesiology, and is planning on grad school.

After Chesser mastered dental endoscopes, she took a look at her life as a single empty nester and decided the time was right to make a move. She left the periodontal office, though she continues to temp and to work one day a week for a general dentist. She took classes through the Small Business Administration, hired an accountant, and formed a limited liability company, Innovative Perioscopy LLC, in June 2012. She purchased two used endoscopes from Dr. Kwan, and a Tony Riso manually tuned ultrasonic unit. She already owned one conventional ultrasonic unit and magnifying loupes.

She contacted the Nevada Dental Board and told them she wanted to work as an independent consultant in general dental offices, using endoscopes to perform their periodontal procedures. She would not diagnose, and she would not be paid by insurance companies or patients, but by the dentists. Her hourly fee is more than hygienists in her area normally make, compensating her for equipment, supplies, and expertise.

The state board advised her to carry on with her plan. Last fall, the board and its legal advisor "asked all the questions they had and unanimously voted to give me their endorsement with their thanks for being proactive in my approach."

Every week in her budding business is different for Chesser. She does a lot of marketing and networking, both inside and outside of the dental community. Once, for instance, she was picking up a box of cookies to take to a dental office, and stopped to put her company logo stickers on the box. The baker asked about her company, then asked for some business cards to pass out to friends.

"Little by little," she says, "I'm getting more calls and going to more offices. Things are picking up. I'm going to stick with it, and it's going to work. My equipment is paid for, and it won't be long before I can support myself entirely with this business."

Hygienist Lynn Groff of southern California is president and CEO of Pocket Resolution, her mobile dental endoscopy care company, setting what she describes as a Gold Standard Advancing Patient Options (www.pocketresolution.com). The company was launched in May 2012, and provides dental endoscopy services to dental offices. She works for each dentist as an employee, offering "a practice within a practice" on an as-needed basis.

"My goal," Groff said, "is to provide an advanced level of care and awareness to dental practices of what we now have the ability to understand and see, allowing higher levels of safe, less invasive patient care." An analogy she uses is, "When we drive a car at night, we use headlights to see. With Perioscopy, we can see subgingivally if we care for our patients accordingly."

She treats patients with unresolved periodontal conditions, and assists in detection of disease-causing agents responsible for tooth and gum infection using the periodontal endoscope. The process, she says, "brings up to 48x magnified vision to 3 mm of tooth surface, revealing details in the subgingival environment."

Because education and treatment planning are such important considerations, Groff has also developed patient education material to assist dentists, and she offers lunch and learn sessions to consider individual offices' needs.

With her business, she said she is "opening a door for a practice to provide patient care at a higher level than our patients expect." Groff said her services bring added value to each practice willing to consider that conventional periodontal treatment has limitations, requiring require an additional level of care to complement current protocols.

Groff credits her childhood dentist and hygienist for sparking her interest in the profession. "I grew up in the Chicago suburbs, and spent a lot of time at the dentist's office. My hygienist, Judy, said this was a wonderful profession for helping people and being able to have a family at the same time. I graduated from Southern Illinois University in Carbondale with an associate degree in 1990, and moved to California in 1991."

After a decade in clinical practice, she and her employer attended an educational event with Dr. Roger Stambaugh and hygienist Gail Myers. Stambaugh and Myers, says Groff, were some of the original clinicians responsible for defining the potential perioscopy would offer dentistry. "In that two-hour evening meeting," she remembers, "I saw, with 48x magnification, what subgingival calculus looked like embedded in the pores of a tooth root. Stambaugh and Myers said that is much of the reason we see chronic unhealed 4+ mm bleeding on probing (BOP) sites."

Groff also learned that in the presence of caries, fractures, and deposits, burnished or not, the sulcular lining develops mirrored patches of granulomatous tissue, which act as a road map to detect the lesions and deposits.

"It blew my mind. I couldn't sleep that night. What I had learned in hygiene school 12 years earlier was now revolutionized by Perioscopy. It was the new gold standard for me."

At about that time, Groff and her husband Steve had their first child, Logan. She supported Dental View as an educator at dental conferences and meetings similar to the one at which she was introduced to dental endoscopy.

"As an educator, I gained great insight into the concerns of dentists and hygienists who were considering Perioscopy. The most interesting detail about what we were all seeing clinically with perioscopy was that BOP confirmed the presence of residual burnished calculus."

As a clinician, she returned to the office of Dr. Marvin Sparks. "He was one of my greatest mentors. He knew I had been specializing in patient care with Perioscopy, so he offered to purchase a scope if I would come back to work for him. When he retired, and my second son Spencer had been born, Dr. Sparks offered to sell me the Perioscope. He knew what providing this level of care meant to me."

She was developing the idea for Pocket Resolution when she met her present employer, periodontist Jin Kim, DDS, MPH, MS, who was interested in offering Perioscopy in his office full-time.

Pocket Resolution came into being in May 2012. She loves working for Dr. Kim two days a week, but in addition, she brings mobile perioscopy care to other dentists' offices. "I want to provide the highest level of patient care possible, but as a partner with each dentist.

"What we're all up to with Perioscopy," she says, "is going to become the norm of hygiene practice. Some will really embrace this technology, and it will be the most exciting, invaluable thing we can do, if we allow ourselves to be open to revisiting what you think you know."

As her business gets under way, Groff knows there is a lot of hard work ahead. "Support from my amazing husband, our family and friends, has been critical to my success. I am passionate about constantly learning and moving forward in dentistry, which to me is my life."

Nancy Kiehl, RDH, MSEd, of Birmingham, Ohio, works with dental endoscopes at the periodontal offices of Dr. Morris Wasylenki of Mansfield, Ohio, and Dr. Eric Guirguis of Elyria, Ohio. Though she started out as a pediatric hygienist, her path has been focused on periodontal care and education. She became a hygienist after she didn't get into the last 2-year nursing program at Massachussetts General Hospital in Boston. "It was fate," she says now. She earned a certificate in dental hygiene at Forsyth School for Dental Hygienists, and an associate in science degree from nearby Northeastern University.

"While I was at Forsyth," she recalls, "I worked in cosmetics at Filene's Department Store. There were homeless people who hung around outside, and I recruited them as patients. I ended up having more experience in periodontics than a lot of other students."

She later worked at a pediatric office in Boston, and at Children's Hospital there. Her next big step was a move to California to enter a post-certificate bachelor's degree completion program at the University of Southern California (now the Ostrow School of Dentistry at USC).

"Off I went," she remembers. "Anna Pattison was the chair of dental hygiene at that time. She met me at the airport and I stayed at her home for several days until I found an apartment. While there I saw a copy of ‘Pattison Periodontal Instrumentation,' and realized she wrote the book I had used in school. Duh! I felt stupid not knowing who she was. The three of us in the post-certificate program saw only periodontally involved patients and worked with graduate periodontology students. We also taught first-year hygiene students, and thus I began my teaching career."

When she graduated from the bachelor's program in 1989, she was offered a part-time position at USC as an associate professor, and completed her master's degree in education. At the same time, she worked part-time at general, pediatric, and periodontal practices.

After 10 years in California, she and her family moved back to her home state of Ohio. She taught and worked in the periodontics department briefly at Case Western Reserve Dental School, then after her daughter was born, worked part-time as clinical instructor and adjunct faculty at Lorain County Community College. She was also active in the Ohio DHA, serving on the government relations committee and as a trustee, and testifying before the state senate on local anesthesia for hygienists.

After a traumatic divorce in 2007, Kiehl went through a period of unemployment during which she was on welfare. "I don't know exactly what the issue was for me, why I couldn't find work," she remembers. "I applied everywhere; I had interviews but nothing panned out. It was humbling, whatever the reason, and now I appreciate my present employment and the recognition I've received even more, having gone through what I did. That's hard to admit because I really struggled for a year or so. I would see my case worker and cry that I had a master's degree and was on welfare!"

Eventually, Kiehl talked to Cheryl Herrmann, an ODHA connection, about working for Dr. Wasylenki. She began there in 2009, and was trained in use of the endoscope by hygienists there, and by Dr. Kwan.

"The hygienists were wonderful to me. They would come in on their days off to make sure I was okay with the scope. I got the hang of it, and now I can't even remember when it was so difficult, and how I thought I would never manage to be good at it."

She said a typical endoscope appointment lasts two to three hours.

"The assistants will usually help set up the equipment: water tanks have to be filled, fiber optics attached, sheaths, instruments, and two ultrasonics have to be set up. It's a big production. Cases vary in difficulty depending on the pocket depths and the amount of calculus on the roots. Patients receive a separate one-hour OHI appointment, and are given a Sonicare toothbrush."

The procedure itself, she says, is sort of like playing a video game, but is very draining physically. "I have massages every two weeks, and use Kinesio tape to help blood flow and to support muscles and tendons that ache. I exercise, take muscle relaxants when necessary, and try not to do all-day endoscopy."

Kiehl feels fulfilled now in her professional and personal lives. Her son is a senior at the Cleveland Institute of Art, and her daughter is a seventh-grader. She loves to read and listen to audio books, and is a big fan of novelist Steig Larsson, especially since a hygienist is featured as a kidnap victim in his last book.

For hygienists who would like to use endoscopy, Kiehl points out an important element of the work: "Take care of your body and keep it strong, because it's very physical work. Continue to educate and challenge yourself. Remember that failure is part of being successful. No one ever made it without struggling along the way."

Hygienist Suzanne Newkirk of Lakemont, Ga., was immediately intrigued the first time she saw a video of the Perioscopy System in 2001. "I felt as if I was on an underwater adventure with Jacques Cousteau, except we were exploring a subgingival pocket. I knew that someday, I would want to utilize Perioscopy as part of my hygiene repertoire, but if that were to happen, I would either have to find a dentist who had a perioscope, or purchase my own. At the time, it was selling for $15,000, which was not in my budget."

Newkirk had fought hard to get into the dental hygiene profession. On the advice of an uncle who was a dentist, she applied to hygiene programs after earning an associate degree and dental hygiene prerequisites at a local community college. "I was not accepted, so I enrolled in a dental assisting program and began working in a dental office." Eventually she moved to Anchorage, Alaska, from southern California in 1979 when she was accepted to the University of Alaska Anchorage dental hygiene program. Since graduation in 1981, she has worked in both general and periodontal practices.

After being exposed to dental endoscopy in 2001, she continued to read everything she could find on it. Four years ago, she was at a critical low point in her career.

"I was in an office where I was bullied and harassed by the staff, and the dentist/owner chose not to intervene. I was so profoundly unhappy that I would come home at night and cry, making my husband and daughter miserable in the process. There were no hygiene jobs available in my area, and I felt as if I was in an untenable situation with nowhere to go."

It was at that point Newkirk decided to act on her dream of using Perioscopy. She purchased a used scope from a local dentist, and went to hygienist Jodi Demming for training. She continued training with Dr. Kwan, who taught her to use manually tuned magnetorestrictive technology with a two-handed technique.

"Having the Perioscope gave me freedom and an outlet for positive energy. I found a passion that I hadn't experienced since I was in school." She founded Perioscopy Professionals (www.perioscopyprofessionals.com) in 2009, and set about finding compatible dental offices where she could use her knowledge and equipment.

Newkirk got in touch with a former employer, Dr. Bob Gottlieb, and his business partner, Dr. Michael Cohen, who is the director and founder of the Seattle Study Club. In early 2010, she began providing Perioscopy at Gottleib's tri-cities office in eastern Washington.

"Working for Bob," she says, "I felt as if I were Cinderella at the ball. I couldn't have asked for more of anything. I had the best employer, co-workers, and equipment that a hygienist could ask for. During that time Bob gave me the opportunity to grow as a person and clinician by not only allowing me to utilize Perioscopy on a daily basis, but to begin lecturing for his dental and dental hygiene study clubs."

Eventually, Gottlieb founded TOH Consulting Services (www.tohconsulting.com), and Newkirk partners with him to help other offices improve their systems and protocols around periodontal therapy.

Newkirk believes the future of dental endoscopy is bright. "Times are really changing, and our professional and state associations have been at the forefront of this. The scope of practice for hygienists will expand along with the needs of the public."

Many states, she says, have some form of general supervision for hygienists outside the traditional dental setting, which provides opportunity for entrepreneurship. For hygienist willing to think outside the box, I believe the future of Perioscopy is limitless."

Ask Dr. Kwan

John Kwan, DDS, of Berkeley, Calif, is the person to talk to if you want to know about using endoscopes in dentistry. Dr. Kwan is the owner of Perioscopy Inc. (www.perioscopyinc.com), and has been using the technology since 2001.

"The main use for the Perioscope is for treatment of periodontal disease," he says. "Because the techniques we use do not require an assistant, this technology is very well suited for use by a hygienist. The vast majority of users are hygienists."

A Perioscope can also be used, Kwan says, for diagnostic purposes or treatment of dental issues like overhanging restorations.

Perioscopy Inc. offers hands-on training for staff hygienists in offices that have Perioscopes. Hygienists can also go to his office to observe. There is a training DVD available, and more than 20 videos on the website. The University of Southern California also has a Perioscopy course, according to Kwan.

Seeing is believing

When I started collecting information for an article on hygienists who use dental endoscopy, I was pleased to discover that one of Nancy Kiehl's offices was relatively close to home. I made the drive to Mansfield, Ohio, to visit the office of periodontist Morris Wasylenki, where Kiehl provides perioscopic services for his patients. Dr. Wasylenki and his staff were kind and accommodating, taking time out of their day to allow me to set up photographs and see a Perioscope in action. They prepped a room while I relaxed and took advantage of a coffeemaker in the waiting area. Surgical assistant Deborah Foss was our model, and Nancy scoped an upper molar as I watched.

The camera is attached to a lighted explorer-size instrument. As she's working, Nancy uses a two-handed technique; that is, she manipulates the scope with one hand, and an ultrasonic scaler with the other. "This is calculus," she said, pointing to the monitor.

It was extremely difficult to make sense of what I was seeing. As Deborah breathed, the image on the monitor vibrated. Every small adjustment Nancy made caused the image on the monitor to flicker and jump. I did manage to identify the calculus formation, but couldn't see the pocket wall or the root surface. Obviously, it would take hours of practice to be confident in manipulating the camera in a pocket, identifying landmarks, and using an ultrasonic scaler concurrently.

Once the technology is mastered, however, imagine the possibilities. A hygienist without the advantage of dental endoscopy is working blind, as we have always done. Don't our patients deserve the best we can give them?

CATHY HESTER SECKMAN, RDH, has written on dental topics for 26 years. She speaks on pediatric issues, and works clinically in a pediatric practice. She is also an indexer and a novelist.

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