Seeing It Up Close and Personal

Dental/surgical operating microscope (DSOM) technology has revolutionized dental specialties such as orthodontics, endodontics, prosthodontics, oral surgery, and dental implantology, enabling dentists to better diagnose and treat complex dental issues. Dental microscopes are designed with specialized optics that provide magnification ranging from 2.5x to 24x, illuminating natural colors and tissue hues to help distinguish between normal and abnormal tissues.³ The design of these microscopes allows the dentist to adjust the focal length and brightness of the light to suit specific treatment and procedural requirements. In orthodontics, DSOMs play an essential role by aiding in the placement of brackets and wires, identifying tooth fractures, and assessing root resorption. The enhanced visibility provided by dental microscopes improves the accuracy of orthodontic treatments, leading to improved patient outcomes.

DSOMs have also long been used in endodontics for visual enhancement and improved ergonomics.⁴ DSOMs are an invaluable tool in prosthodontics as well, ensuring the accuracy of crown and bridge preparations, denture fittings, and implant restorations. The magnification provided by these microscopes makes it easier to identify any complications accurately, helping ensure a proper restoration for the patient. DSOMs are also widely used in oral surgery, helping dental professionals identify anatomical landmarks and vessel patterns to prevent damage to vital structures such as nerves and blood vessels. They also aid in the identification of complex anatomical regions, such as the maxillary sinus and temporomandibular joint. In addition, DSOMs have transformed the field of implantology, helping identify any irregularities or complications during implant placement. This improved vision helps ensure that the implant is placed correctly, allowing the patient to have a more comfortable postoperative experience.

Dental hygiene, on the other hand, has relatively limited application for DSOMs because of their narrowed field of view. DSOMs are engineered to provide superior control over micro-motor muscles and joints, such as fingers and wrists, in microsurgical procedures where precision is of the utmost importance.³ Advancements in technology have led to new models of DSOMs that integrate technologies such as variable focus, 4K imaging, and augmented reality. DSOM technology continues to evolve, providing dentists with superior visualization of dental anatomy, leading to better patient outcomes. As the technology continues to advance, the possibilities of this innovative technology within dentistry are limitless.

The periodontal endoscope is a valuable diagnostic tool, specifically in the field of periodontology. Endoscopes allow the healthcare professional to observe internal structures through orifices or small surgical openings.⁵ Its primary use in periodontal therapy is to provide subgingival visualization. The periodontal endoscopic system is an imaging system with a fiber-optic cable used to transmit light to and from the area to be viewed, usually less than 1 mm.⁵ The images are displayed on screen and can be magnified up to 48 times to provide a detailed view of the affected area.⁵ This system is used in conjunction with hand instruments and ultrasonics to locate subgingival deposits that may be missed during traditional nonsurgical periodontal therapy. This makes it particularly valuable for dental hygienists, who can use the endoscope to achieve better treatment outcomes. The endoscope can help locate stubborn subgingival deposits, resulting in improved treatment outcomes and greater periodontal health. Clinical applications of the periodontal endoscope include initial periodontal therapy with pocket depths measuring greater than 4 mm, treating sites that have not responded to traditional nonsurgical debridement, periodontal maintenance for patients with chronic inflammation, increasing probing depths, and treating those who refuse surgical therapy or for whom surgery is contraindicated for medical or esthetic reasons.⁶ Clinical applications also include use on patients with suspected subgingival pathology, such as root fractures, endodontic root perforations, or resorption.⁶ By providing superior subgingival visualization, the periodontal endoscope has an important role to play in the future of periodontal therapy.

Dental loupes are specialized magnifying devices used by oral healthcare professionals. They provide increased magnification, allowing the user to see details that cannot be seen with the naked eye. Loupes come in a variety of magnification levels and designs and with a variety of compatible accessories, providing enhanced accuracy and precision when performing dental procedures. Additionally, advancements in this technology have improved visibility and working comfort while helping dental professionals maintain an ergonomic posture. Loupes can be beneficial as an aid during patient assessment, dental procedures involving hard and soft tissue evaluation, periodontal instrumentation, and radiographic interpretation.⁷ With dental loupes, wearers can expect to see a magnified image with brilliant illumination along with improved efficiency and precision during dental procedures. Loupes are well supported in the literature to improve ergonomic health by decreasing bending and slouching, thus preventing musculoskeletal disorders and cumulative injury for dental hygienists.⁸ However, the use of poorly selected or fitted loupes may increase the risk of musculoskeletal disorders. Choosing the right pair of loupes is paramount to the tool's success. It is vital that clinicians are properly fitted for loupes, and it is unadvisable for practitioners to exchange loupes with colleagues or to purchase a used pair. Doing so can cause more harm.⁹

There are several types of loupes available, however only three types are typically used by dental hygienists: Galilean loupes, prismatic loupes, and EyeZoom loupes, each with their own advantages and disadvantages. Galilean loupes are the most popular among dental hygiene professionals.⁷ They are lightweight, have a wider field of vision, and offer magnification of around 2.5x to 3.5x. On the other hand, prismatic loupes offer higher magnifications (3.5x to 6x) and a more compact design, but they are heavier and have a smaller field of view. EyeZoom loupes offer adjustable magnifications but are bulkier when compared with the other two. The choice between these three types of loupes depends on the required magnification, working distance, and comfort level.

There are two common mounting styles for ergonomically designed loupes: Front-lens-mounted (FLM) style and through-the-lens (TTL) loupes. The telescopes on the FLM loupes are mounted on the carrier lens, as the name suggests. They are ideal for clinicians who are unsure of their desired declination angle. This style allows the clinician to try different declination angles to achieve optimal neck posture. This mounting style is best for those with a flat nose bridge. TTL have telescopes mounted through the carrier lens, and this style of loupe is suitable if the declination angle is already known; however newer designs for TTL loupes have adjustable nose pads to account for anatomical variations.

A dental loupe comprises several components that impact its performance. These include:

• Working distance: The distance between the object and the loupe's front lens. This distance hinges on the height of the operator chair, whether the wearer is sitting or standing, posture, and clinician height. To measure the clinician's ideal working distance, the head must be held erect with arms positioned at a good working height.

• Depth of field: The range of clear vision through the telescopes/oculars within the working distance without having to adjust head or neck position.

• Field of view: The size of the object visible through the loupe. This measurement determines if the clinician can see the entire mouth or just a few teeth. A wider field of view enables dental hygienists to see more teeth and surrounding tissues at once.

• Interpupillary distance: The distance measured between the centers of the pupils of the eyes.

• Magnification: Magnification refers to the degree of enlargement provided by the dental loupes. The higher the magnification, the greater the visual acuity, but the narrower the field of view. Most dental hygienists prefer loupes with a magnification of 2.5x to 3.5x as they provide a good balance.

• Clarity: Clarity refers to how clearly the microscopic image appears through the telescopes. This factor is a function of the magnification power and the quality of optics used in the loupe.

• Image quality: Image quality is determined by the resolution, depth of field, and light transmission. Resolution refers to the level of detail that can be seen in the image. The higher the resolution, the more precise the image. Light transmission refers to how much light passes through the lenses of the loupe, which can affect color accuracy and brightness. Higher quality loupes will have superior image quality characteristics, resulting in a superior imaging experience.

• Declination angle: Angle of declination refers to the angle at which the loupes sit on the face. An optimal angle of declination reduces the strain on the neck and back and enhances overall comfort during prolonged use. The greater the declination angle, the less the user has to tilt their head.

Clinicians should consider the following design features when deciding what type of dental loupes to purchase:

• Frame size: The frame size should be ideal for the user's head. Companies manufacture different frame sizes to accommodate the different sized heads and different facial structures.

• Weight: Because heavy loupes can cause neck and shoulder strain, dental hygienists should select loupes that are lightweight and well-balanced.

• Carrier lens: The carrier lens is the actual lens on the loupe, not the oculars or telescope. The carrier lens height is measured from the top of the lens to the bottom. This measurement impacts the declination angle. Larger carrier lenses are recommended to accommodate a steep declination angle.

• Frame material: There are various materials used to design loupe frames, including stainless steel, titanium, plastic, and hybrid material. Stainless steel is durable but can be heavy, while titanium offers sturdiness and flexibility within the temple arms. Plastic frames are lightweight but not as durable as stainless-steel frames. Some hybrid designs combine stainless steel with aluminum to offer strength and flexibility.

There are several brands of dental loupes available on the market, each with unique design features. Selecting the right dental loupe is essential for clinicians looking to enhance visual acuity, improve accuracy, and support ergonomic health. Clinicians should select loupes that meet the required specifications for their work environment. This includes determining the appropriate working distance, magnification strength, field of view, and declination angle. When selecting loupes, it is essential to consider the weight, lens quality, and loupe frame design.

Understanding the different parts of a dental loupe, the impact of design features on selection, and the advantages and limitations of dental loupes can help clinicians make informed decisions when choosing loupes for their work environment.

Dr. Joy D. Void-Holmes, founder of Dr. Joy, RDH^™ and co-founder of JELL-ED^™, is a registered dental hygienist with over 26 years of experience. She holds a Doctor of Health Science degree and has presented continuing education courses nationally and internationally. Dr. Joy serves as a consultant for various advisory boards and is an active member of several professional organizations.