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Journal Club on Ultrasonography

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Journal Club on Ultrasonography

  1. 1. 1
  2. 2. Ultrasonography For Chairside Evaluation Of Periodontal Structures: A Pilot Study P R E S E N T E D BY : - D R K . A B H I L A S H A M O D E R AT E D BY : - D R R U PA M A L I N I D E PA R T M E N T O F P E R I O D O N T I C S
  5. 5. • Diagnostic testing has been a great challenge in Periodontology. • It is primarily derived from information obtained from the patient’s medical and dental histories combined with findings from thorough oral examination. • The entire constellation of signs and symptoms associated with disease and the additional information provided by radiographic imaging is taken into consideration before arriving a diagnosis. • A better understanding of the periodontal disease process challenged usefulness of traditional clinical and radiographic methods for diagnosis and prompted revision of outdated diagnostic aids. 5
  7. 7. • Dental Radiographs are traditional method to assess destruction of alveolar bone. • Primary criterion for bone loss is the distance from CEJ to the alveolar crest and distance more than 2 mm is considered as the bone loss. CONVENTIONAL ADVANCED 7
  8. 8. CONVENTIONAL RADIOGRAPHS 1.Periapical radiograph 2.Bitewing radiograph 3.Occlusal Radiograph 4.Panoramic radiograph 8
  9. 9. • More than 30% of bone mass at alveolar crest must be lost to be recognized on radiographs • Radiographs provide a 2-dimensional view of a 3- dimensional situation. • Provides only information about inter proximal bone level. • Radiographs do not demonstrate soft tissue - to – hard tissue relationship hence no information about depth of soft tissue pocket LIMITATIONS OF RADIOGRAPHS * Conventional Radiographs Are Specific But Lack Sensitivi 9
  11. 11. CONE BEAM COMPUTED TOMOGRAPHY • Developed in 1982 for angiography • In recent years, this technology for acquiring 3D images of oral structures is now available to the dental clinics and hospitals. • PRINCIPLE- A thin fan beam of X-Rays rotates around the patient to generate in one resolution around thin axial slice of the area of interest. • Utilizes cone shaped source of ionizing radiation & 2D area detector fixed on a rotating gantry . 11
  12. 12.  Rotates 360° around the head  Scan time typically < 1 minute 12
  13. 13. • Image acquisition involves a Rotational scan of a x ray source and reciprocating area detector moving synchronously around patients head. • Many exposures are made at fixed intervals to form basic images. • Software programs are used to reconstruct 3D images. 13
  15. 15.  Poor Soft Tissue contrast- due to scattering based radiations and presence of panel detector based artifacts.  Image noise is due to large volume being irradiated during CBCT scanning resulting in heavy interactions with tissues producing scattered radiation.  CBCT is not applicable for evaluating peri-implant structures due to beam hardening and scattering artifacts (Gonzalez- Martin et al. 2015; Kuhl et al. 2015).  Exposure to ionizing radiations.  Steep financial costs. LIMITATIONS OF CBCT Although CBCT has made a speedy ingress into the field of dentistry, currently it is not devoid of drawbacks, 15
  16. 16. Nevertheless, The Terms Ultrasound And Ultrasonic When Used In Dentistry Refer Almost Always To The Kilohertz-frequency Vibrating Tips Used For Scaling Teeth And Not To Diagnostic Imaging (Ultrasonography) As In Medical Diagnostics And Industrial Inspection. 16
  18. 18. INTRODUCTION • Sound has been used clinically as an alternative to light in the diagnostic evaluation of variety of conditions. • Advantage of sound over light is it can pass through opaque tissue. • An important tool in terms of diagnosis and management. • Sonography–technique based on sound waves that acquire images in real time without the use of ionizing radiation‘‘Ultra’’ means beyond or in excess ‘‘Sound’’ means audible sound energy ULTRASOUND 18
  19. 19. • The human ear can respond to an audible frequency range, roughly 20 Hz - 20 kHz. • Ultrasound Waves are acoustic waves with frequencies at or above 20 kHz 19
  20. 20. HISTORY • In the year 1926, Paul Langevin was the first to report the biological effects of ultrasound. • In1942 Dussik K .T & Friederick reported the first successful application of ultrasound to medical diagnosis • The first use of diagnostic ultrasound in dentistry appears to have been by Baum et al. In 1958. • In 1971 Dalyand Wheeler carried out ultrasound imaging of dental soft tissues to find out the use of ultrasonic measurement in clinical evaluation of oral soft tissues. 20
  21. 21. MECHANISM Scanners used for sonography generate electrical impulses that are converted into ultra-high-frequency sound waves by a transducer Sound waves travel into body and hit the tissues and organs Some of them are partially reflected from the interface between different tissues and returns to the transducer Transducer calculates the distance from it to the tissues and transmits the echoes electrically onto a monitor. 21
  22. 22. ULTRASOUND PROBE (TRANSDUCER)  Device which converts one form of energy to other  In US, it converts electrical energy to ultrasonic energy {PULSE} & vice- versa {ECHO}  Transducer is both a transmitter & a receiver 1. Piezoelectric crystals 2. Two electrodes 3. Backing layer 4. Matching layer 5.Acoustic insulator 6. Plastic housing
  23. 23. INTERACTION WITH TISSUES Ultrasound waves interact with tissue in four basic manners. Reflection Scattering Refraction Attenuation 23
  24. 24. • Reflection occurs when the ultrasound wave is deflected towards the transducer. • The major factors affecting the amount of reflection are:- REFLECTION 1. Angle of incidence 2. Width of Tissue Boundary 3. Acoustic Impedence Mismatch 4. Angle of Tissue Boundary 24
  25. 25. • Scattering occurs when the width or lateral dimension of the tissue boundary is less than one wavelength • If a large number of small tissue boundaries occurs, the scattering can radiate in all directions. • The signal that reaches the transducer is a much weaker signal than the transmitted signal and is typically 100-1000 times (40 - 60 dB) less than the transmitted signal. SCATTERING 25
  26. 26. • Refraction occurs when the ultrasound signal is deflected from a straight path and the angle of deflection is away from the transducer. • Ultrasound waves are only refracted at a different medium interface of different acoustic impedance • Refraction allows enhanced image quality by using acoustic lenses. • Refraction can result in ultrasound double-image artifacts. REFRACTION 26
  27. 27. • Attenuation is the result of an ultrasound wave losing energy. • As the ultrasound wave travels through a medium, the medium absorbs some of the energy of the ultrasound wave. • The amount of energy absorption, or acoustic impedance , is determined by the product of the density of the medium and the propagation velocity of the ultrasound wave ATTENUATION 27
  28. 28. APPLICATION IN DENTISTRY 28 Alok A, Singh S, Kishore M, Shukla AK. Ultrasonography–A boon in dentistry. SRM Journal of Research in Dental Sciences. 2019 Apr 1;10(2):98.
  29. 29. 29 Alok A, Singh S, Kishore M, Shukla AK. Ultrasonography–A boon in dentistry. SRM Journal of Research in Dental Sciences. 2019 Apr 1;10(2):98.
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  34. 34. ARTICLE 34
  35. 35. AIM OF THE STUDY To Evaluate The Correlation And Accuracy Of Ultrasound (US) In Measuring Periodontal Dimensions, Compared To Direct Clinical And Cone-beam Computed Tomography (CBCT) Methods. 35
  36. 36. INTRODUCTION 36
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  39. 39. MATERIALS AND METHODS • This study was approved by the University of Michigan Institutional Review Board and was conducted in accordance with the Helsinki Declaration of 1975, as revised in 2013. • All patients signed an informed written consent to participate in the study. • A sample of 20 participants scheduled for a Single Implant Surgery, at the University of Michigan School of Dentistry, Department of Periodontics and Oral Medicine, were recruited for this pilot study. RECRUITMENT 39
  40. 40. • The participants were deemed eligible if they had a Maxillary Or Mandibular Single Edentulous Area At The Anterior Or Premolar Site With Two Immediately Adjacent Teeth On Both Sides Available. • The sites of interest in each individual patient were the Mesial And Distal Tooth, in addition To The Edentulous Site for an implant placement. 40
  41. 41. • Following 6 parameters were measured:- QUANTITATIVE DATA ACQUISITION 1. PH 2. CBL 3. STHt 4. MTt Interdental papilla height (PH): the vertical distance from the tip of the facial papilla to the crestal bone on the mesial and distal papillae of a given tooth. The crestal bone level (CBL) at teeth: the vertical distance between the alveolar crest and the cemento- enamel junction (CEJ) or the restoration margin on the midfacial site of the imaged tooth. Mid-facial soft tissue height at teeth (STHt): the vertical distance from the free gingival margin to the crestal bone at the mid-facial site of a given tooth. Soft tissue height at the edentulous ridge (STHe): the vertical distance from the external border of the cortical bone to the most superficial level of the crestal soft tissue in the center of the gap. Mucosal thickness at the edentulous ridge (MTe): the horizontal distance between the mucosal surface to the underlying bone surface, measured at 3 and 6 mm from the mucosal margin at mid-facial and mid-palatal sites. 5. STHe 6. MTe Mucosal thickness at teeth (MTt): the horizontal distance between the mucosal surface to the underlying bone or root surface measured at 2 and 5 mm from the gingival margin at mid-facial sites 41
  42. 42. CBCT scans were acquired for participants who did not have a clinically ordered scan for the planned implant surgeries. Scans were used to acquire crestal bone levels and soft tissue-related parameters as an additional reference for comparison to US readings All scans, were obtained using a CBCT device with scanning parameters of 120 kVp, 18.66 mAs, scan time of 20 seconds, and resolution of 250 μm. CBCT SCANS 42
  43. 43. ULTRASOUND (US) SCAN • The US scan was a separate visit usually within 2 weeks before the implant surgery date. • Ultrasound scan was performed using a US image probe prototype • US IMAGE PROBE PROTOTYPE The 24 MHz imaging probe prototype dimension is comparable to that of a toothbrush and its cable runs perpendicular to the aperture, allowing for cross-sectional scans to the 2nd molars. The maximal transducer thickness, width and length is 15, 16.2 and 30 mm. Its axial and lateral image resolution is 64 and 192 µm, respectively, with an optimal penetration depth of 15 mm, and in real-time image acquisition. 43
  44. 44. • Acoustic coupling was achieved with mounting a gel-based stand-off-pad to the probe aperture and applying US gel between the pad and the oral structures. • The mesial and distal teeth adjacent to the edentulous gap in each participant were scanned at the mesial and distal papillae and midfacial surface with the transducer placed approximately in line with the long axis of the particular tooth. • The included edentulous gaps were scanned at the mid-facial and mid-lingual surfaces. • The participants wore a customized acrylic reference guide during the US scans. • The same guide was used during the CBCT scan and direct measurements to minimize measurement site variability among the three methods. 44
  45. 45. 45
  46. 46. • At the implant placement visit, PRIOR to elevating a full thickness flap, the papilla and mucosal height of teeth and mucosal thickness at the dentate and edentulous sites were measured. • Interdental papilla height and facial mucosal height around teeth were measured with a calibrated periodontal probe to the closest 0.5 mm. • AFTER facial flap elevation, the remaining measurements (i.e. the mucosal height at the edentulous gap and crestal bone level) were made with the same periodontal probe. • To clinically measure mucosal thickness, a #25 endodontic file was used. • The file was inserted perpendicular to the mucosal surface. The distance between the tip of the file to the rubber stop (i.e. the mucosal thickness) was measured using a metric digital caliper, precision to 0.01 mm DIRECT MEASUREMENTS 46
  47. 47. • The inter-rater correlation coefficients (ICC), root mean square error (RMSE) and maximum differences were calculated to evaluate the strength of agreement between US measurements from both readers. • The pairwise agreement between the direct, US and CBCT measurements were also assessed by ICC. • Bonferroni corrections were used to adjust the significance level as 0.0083 (=0.05/6). • F-tests were employed to examine if the p-values of the ICC were significantly greater than 0. DATA ANALYSIS 47
  48. 48. • The ICC ranges from -1 to 1, where an estimate of 1 indicates perfect agreement and 0 means random agreement. Negative ICCs indicate a systematic disagreement. • Commonly-cited cut-offs are – POOR for ICC values less than 0.40, – FAIR for values between 0.40 and 0.59, – GOOD for values between 0.60 and 0.74, and – EXCELLENT for values between 0.75 and 1.0 • Bland-Altman plots were also created to evaluate the differences between US, direct measurements, and CBCT readings and clinical significance. 48
  49. 49. RESULTS • A total of 20 participants (15 male and 5 female), with a mean age of 61.2 ± 13.4 years. • The study sample accounted for 40 teeth (anterior teeth (27) and posterior teeth (13) sites) and 20 edentulous ridges (anterior (16) and premolar (4)). • Of these sites, 51 sites were in the maxilla (34 tooth sites and 17 edentulous sites), while 9 were in the mandible (6 tooth sites and 3 edentulous sites). DESCRIPTIVE ANALYSIS 49
  50. 50. INTER-RATERAGREEMENT <0.0001* 50
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  54. 54. DISCUSSION 54
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  60. 60. CONCLUSION 60
  61. 61. With encouraging 1st time human data displaying satisfactory measurements of periodontal soft and hard tissue dimensions, US imaging could become a valuable tool for real-time, cross- sectional evaluation of the periodontia without concerns of ionizing radiation and metallic artifacts. Future research should focus on the ability of US to differentiate periodontal disease from healthy status. 61
  62. 62. REFERENCES 62
  63. 63. • Principles and Practice of Oral Medicine, Stephan S Sonis, Fazio, Fang • Chifor R, Badea ME, Vesa ŞC, Chifor I. The utility of 40 MHz periodontal ultrasonography in the assessment of gingival inflammation evolution following professional teeth cleaning. Medical ultrasonography. 2015 Mar 1;17(1):34-8. • Nguyen KC, Pacheco-Pereira C, Kaipatur NR, Cheung J, Major PW, Le LH. Comparison of ultrasound imaging and cone-beam computed tomography for examination of the alveolar bone level: A systematic review. PloS one. 2018;13(10). • Tsiolis FI, Needleman IG, Griffiths GS. Periodontal ultrasonography. Journal of clinical periodontology. 2003 Oct;30(10):849-54. • Sainu R, Madhumala R, Thouseef MA, Ravi S, Sayeeganesh N, Jayachandran D. Imaging techniques in periodontics: a review article. Journal of Bioscience And Technology. 2016;7(2):739-47.63
  64. 64. • Chan HL, Wang HL, Fowlkes JB, Giannobile WV, Kripfgans OD. Non-ionizing real-time ultrasonography in implant and oral surgery: A feasibility study. Clin Oral Implants Res 2017;28:341- 347 • e-EchoCardiography- An Echocardiographic interactive Course and Resource (Webpage by American Society of Radiologic Technologists (ASRT)) • Ghorayeb SR, Bertoncini CA, Hinders MK. Ultrasonography in dentistry. IEEE transactions on ultrasonics, ferroelectrics, and frequency control. 2008 Jun 3;55(6):1256-66. • Chan HL, Wang HL, Fowlkes JB, Giannobile WV, Kripfgans OD. Non‐ionizing real‐time ultrasonography in implant and oral surgery: A feasibility study. Clinical oral implants research. 2017 Mar;28(3):341-7. • Kumar S B ,Mahabob N Ultrasound in dentistry–a review JIADS2014;1:44-45 64
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Notas del editor

  • Further due to advances in computing power and ultrasound technology, research on dental ultrasonography has expanded considerably…