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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

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PRESENTATION LAYOUT
• INTRODUCTION
• RADIOGRAPHIC DIAGNOSTIC AIDS
• CONE BEAM COMPUTED TOMOGRAPHY (CBCT)
• ULTRASONOGRAPHY
– HISTORY
– MECHANISM
– INTERACTION WITH TISSUES
– APPLICATION IN DENTISTRY
• ARTICLE
– INTRODUCTION
– MATERIALS AND METHODS
– RESULTS
– DISCUSSION
– CONCLUSION
• REFRENCES
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INTRODUCTION
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• 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methods for diagnosis and prompted revision of outdated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.
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RADIOGRAPHIC
DIAGNOSTIC
AIDS
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• 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
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CONVENTIONAL RADIOGRAPHS
1.Periapical
radiograph
2.Bitewing
radiograph
3.Occlusal
Radiograph
4.Panoramic
radiograph
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• 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
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ADVANCED RADIOGRAPHS
DIGITAL RADIOGRAPHY
SUBTRACTION RADIOGRAPHY
COMPUTER ASSISTED DENSITOMETRIC IMAGE
ANALYSIS
CONE BEAM COMPUTED TOMOGRAPHY
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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
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 Rotates 360° around the head
 Scan time typically < 1 minute
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• 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.
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INTERFACE CONE-BEAM CT MANAGEMENT
SOFTWARE
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 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,
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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.
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ULTRASONOGRAPHY
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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
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• 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
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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.
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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.
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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

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INTERACTION WITH TISSUES
Ultrasound waves interact
with tissue in four basic
manners.
Reflection Scattering Refraction Attenuation
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• 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
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• 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
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• 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
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• 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
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APPLICATION IN DENTISTRY
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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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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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ARTICLE
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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.
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INTRODUCTION
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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
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• 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.
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• 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
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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
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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.
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• 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.
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• 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
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• 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
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• 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.
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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
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INTER-RATERAGREEMENT
<0.0001*
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DISCUSSION
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CONCLUSION
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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.
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REFERENCES
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• 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

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• 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
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