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Ultrasonography for Wound Healing Evaluation with Drs. Benyapha Sirinirund, Hsun Liang (Albert) Chan, and Oliver Kripfgans
184 Plays4 months ago
In this episode, we dive deep into the use of ultrasound imaging in dentistry and periodontology. Listen as Dr. Flavia Pirih, Co- Editor of Clinical Advances in Periodontics, interviews Drs. Benyapha Sirinirund, Hsun-Liang (Albert) Chan, and Oliver Kripfgans on their research looking at the use of ultrasonography to predict wound healing outcomes.
Read the full article here. https://aap.onlinelibrary.wiley.com/doi/10.1002/cap.10234
This podcast is produced by the American Academy of Periodontology (AAP). To learn more visit perio.org.
The views expressed in this episode are those of the participants and not necessarily those of the AAP.
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Transcript
Introduction to Periodontology Research
00:00:00
Speaker
Whether you are in training, in practice, or in research, the Journal of Periodontology and Clinical Advances in Periodontics have something new for you.
Case Report on Ultrasonography in Periodontics
00:00:34
Speaker
So they were very excited to have ah three authors of a very exciting manuscript on one healing evaluation with ultrasonography. This is a case report that has been published in the clinical advances in periodontics. I'm Flavia Pidi. I'm one of the editors of the CAP, and I'll have everybody introduce themselves. Hello. Hi, everyone. Thank you, Flavia, for this great opportunity. This is Albert Chen, and I'm currently at the Ohio State University. I'm here at the Period Division.
00:01:07
Speaker
Hi, I'm Albright, I'm from the University of Michigan. I'm an associate professor of radiology. And then I'm Benya Pasiriran. I'm a full-time faculty at Chiang Mai University at Division of Periodontics.
Benefits of Ultrasound in Guided Bone Regeneration
00:01:22
Speaker
All right, so can you guys walk us through your paper?
00:01:25
Speaker
So I'm studying my residency in 2019 and I just start like doing like guided born regeneration, maybe in 2020.
00:01:38
Speaker
And at that time, I think the case was um very first my very first DVR, and I worked with Dr. Shan trying to understand how to treatment planning my surgery. And Dr. Shan grabbed me ultrasound probe, and then he started to visualize the soft tissue structure.
00:02:01
Speaker
as well as bone structure. At that time I was like, oh, what is this? And then I, treatment, carefully treatment planning with him and then the under sonography for the guided bone regeneration really helped me understand the structure of the soft tissue as well as the hard tissue surface.
Advantages of Ultrasound over CT Scans
00:02:25
Speaker
So that's why we wrote the case report that shows how the imaging, ultrasound imaging could help like me understand better and help a surgeon do their treatment planning. So what do you think is the advantage of using the ultrasound?
00:02:45
Speaker
After I graduated from my residency, I've been doing a lot of research related to ah radiation, common CT, 3D dimensional images. And I start to realize there's some certain limitations about common CT. One of the biggest obstacles are the the the soft tissue contrast is not as good with the common CT. You don't really see soft tissue very well. um And another part would be um the common city you have all the scatterings from the algorithms that you use and the artificial um ah artifacts that relate to the inherent limitation of how the common city was ah the beans was formulated. That's why I got so interested in what were are the mechanisms or technology that can be used
00:03:39
Speaker
to already exist in the medical field that can look at soft tissue healing and also the soft tissue anatomy as well and I figure out that ultrasound will be the best image modality for soft tissue imaging and also on top of that there's no radiation, it's a free radiation related to ultrasound and top dot you have the cross-sectional imaging that's different from 2D X-ray. You see the buccal lingo dimensions as well. And also the functional analysis, the dynamic evaluation, look at possible blood flow that's pretty much opened my eyes.
Decade of Collaboration in Ultrasound Technology
00:04:17
Speaker
that's that's Those are the advantages that the
00:04:21
Speaker
the radiation, the current radiation images that cannot offer that can be offered by ultrasound. That's why I got so interested in this and work with Oliver's and advanced this technology so far.
Applications of Ultrasound in Dental Practice
00:04:36
Speaker
So how long have you and Oliver been working? Oliver?
00:04:42
Speaker
Well, I can say happy 10th anniversary. ah We have been collaborating since 2014. And I think you have already like 27 publications or something like that. I think we crossed the 30. Okay, so I have to do a better search. No, no, no, that's okay. It's been an amazing journey. Of course, there are ups and downs and really that's an amazing journey.
00:05:08
Speaker
All right, so walk us through a little bit more the you know on the paper. How do you interpret the color of the the ultrasound? How do you distinguish between the bone and soft tissue? Could you walk us through a little bit more on what you see in this particular paper?
00:05:25
Speaker
So basically for ultrasound, you can use for like a treatment planning phase and during the surgeries and we have publications about that and also after the surgery as well for wind healing analysis. During the treatment planning phase, you basically can look at as simple as look at anatomy and to see what's the soft tissue thickness.
00:05:51
Speaker
and where the keratinized tissue is, the mucosa and the muscle attachment. Also your basic ah baseline level of um vasculature, superperior osteoplexus, which is the the primary blood supply to your flap so that you can really have idea of how you design your flap based on the ah soft tissue anatomy that currently you you don't have that information. And then during the surgery, ah before even before the surgery, you can look at a soft heart tissue interface pretty nicely so you can understand the thickness of your reach and you can decide if you want to do a stage approach or you can do simultaneous implant placement.
00:06:42
Speaker
And after surgery, that's come to the big advantage too. And you can look at ah blood perfusion during the healing and see if there's a potential issues with the reperfusion. And that's the biggest issue for wound opening. That's the the primary complication for guided bone regeneration. And that you can see with the ultrasound.
00:07:07
Speaker
And also just along the healing process, you can look at the first time you can look into the soft tissue and see how stable your wound is and your bone particulates and your membranes. And also this is quite amazing that you don't have the technology currently.
00:07:28
Speaker
in the clinic that you can see. So those are the things that we or we even like looking at ah as early as 10 days of the healing, then we can already kind of predict what will happen at five months based on the ultrasound images that we had recently, the studies and look at all the cases.
Challenges in Ultrasound Adoption
00:07:48
Speaker
So that's quite amazing how ultrasound can do. So we're really looking forward to like more data and to show that the the benefit of using ultrasound.
00:07:58
Speaker
Since we're talking about the benefits, what are the disadvantages at this point of using the ultrasound? Are there at disadvantages? Yeah. ah So one one is acceptance. um I think the world is full of great ideas and everybody thinks the idea is the greatest. And ah some people um actually don't think that ultrasound is needed. Somebody recently said that if I want to see if there's a lesion or if there's an issue with with with an implant, I can just open a flap and I can take a look.
00:08:34
Speaker
which seems odd because doing a surgical incision. So ultrasound is is is wonderful that you can look inside of the tissue, but ultrasound needs, for example, coupling gel. So as opposed to x-ray,
00:08:50
Speaker
ah You cannot just take a patient and do an ultrasound exam. You need to have an ultrasound device, a probe. You need to prepare it. You need to have ultrasound gel. And so there is some there is some ah planning, or not planning, but there is some procedure needed that people need to become accustomed to. And then ultrasound is not part of the curriculum currently. So for a lot of people, ultrasound is new.
00:09:14
Speaker
and there might be either a natural reaction to be ah worried about this not being quite useful or there could actually be curiosity and people might actually be drawn towards it. It's like if you take a cell phone and you give it to somebody that never had a cell phone, they might not know what to do with it or they could say, what is this? Let me let me take a look. So it really depends. Now,
00:09:38
Speaker
ah one One chance that we found that was actually quite amusing was us um some of the distribution folks didn't know what to do with dentists. So it's actually on both sides. So the ultrasound manufacturers, they are new to interacting with dentists.
00:09:55
Speaker
And then dentists are new interacting with ultrasound. So there is some matchmaking that needs to be done.
Learning Curve for Dentists Using Ultrasound
00:10:00
Speaker
But overall, ultrasound has amazing capabilities that are currently not, how should I say, ah used to the fullest in in dentistry. And this needs to come. And then manufacturers need to adapt to a new market. And they need to see what makes ultrasound even more useful or ah better workflow in in dentistry. And that will all come as as we find out what the best applications are and as we start using it in the clinic. I mean, as you mentioned, I mean, just the fact that you don't have to do a surgery, that you may be able to see things without it, that's huge. I think that's a huge application. So if individuals knew about that or dentists
00:10:41
Speaker
become aware of the potential. That seems pretty impressive. I mean, it seems to me like a selling point. I mean, why should you know how to do this or use this? And what's the size of the probe?
00:10:56
Speaker
size of a toothbrush so it's about 16 millimeters yeah it's 16 millimeters thick 13 millimeters on the side and then it extends with a cable just like a toothbrush so just like the bristles of a toothbrush that are extending sideways towards the ground the gums ah that's That's how the image is is formulated. So you do a sagittal image, so it's it stands vertical. And with that image orientation, you can reach with the probe inside of the mouse, you can reach the molars, and you can do this on the buccal and the lingua palatal side as well. And you get a nice cross-sectional view of the iviola mucosa, the gingiva and the crowns and roots and bone. Very exciting. And what's the learning curve?
00:11:46
Speaker
it i mean it It sounds like a daunting learning experience, but to be honest, by Just explain to you about the ultrasound and cross-sectional view and it almost take less than a day to understand how to read the imaging. So that's ah as fast as you can get. i we We show residents and when we give lectures and show the ultrasound images to the participants almost like immediately people get the sense.
Ultrasound for Early Diagnosis and Intervention
00:12:21
Speaker
of how the ultrasound works and in terms of the scanning that's a little bit learning curve maybe takes a couple weeks and I can guarantee you our dentist is probably the best ah sonographer because we have the tactile feeling and for the ultrasound to really work you You have a gel in between your probe and then the structure which is your soft tissue. You not necessarily want to put too much pressure like ah OB or other like a medical field where you can put pressure on the soft tissue. In the dental you can because by pushing pressure on the the soft tissue you change the dimension of the soft tissue.
00:13:01
Speaker
So I think we're really good at that because we do like delicate procedures, especially for paredontist, we're really good at a soft tissue handling. So I think for the most part, from our experience, our like our trainees graduate from our program, I think probably take about couple of weeks, most people can get a good sense of how you do the skin. What do you think, Benyapa?
00:13:28
Speaker
Oh, I think so because um when, especially periodontist, right? We are periodontist, we know the structure of soft tissue really well, like what is outside, epithelium, connective tissue, what is inside. So for me, ah personally, and it's not that hard because if I know the structure, meaning that I know where to take the skin. And also one more thing is that um I agree with ah Dr. Shan that um our hand is like so delicate we manipulate the soft tissue all the time and um
00:14:08
Speaker
In order to scan the soft tissue structure, you need to kind of like floating the ultrasound flow, floating above the surface a little bit to not um making extra pressure on the soft tissue so that you can visualize the soft tissue thickness, make sure that the structure is not um dimensional change. And it's quite a bit ah bit of learning, but it's not impossible.
00:14:38
Speaker
Take a couple of weeks, light up the chancy. Have you compared the accuracy with CT scan or what are the advantages of using this compared to the CT scan? Yeah, we we we had a ah series of studies and look at anatomical structures, the soft tissue and the hard tissue dimensions compared to CT and the gold standard, which is our direct measurements and publishing JOP and the plus one.
00:15:07
Speaker
and the radiology journals and basically our pro one of the advantages our ultrasound probe is a high resolution and working with the company and Oliver back in when I don't remember this few years back so that's a that's a quite advancement how we can We can produce a prototype and now it's off-shelf. Now it's a clinical available device that you can buy on the market already and that with the resolution of less than 100 microns. Compared to COVID-CT, usually the clinical use ones is going 200 to 300 microns.
00:15:49
Speaker
So internal resolution is much better and now we're looking at the microscopic imaging like a level using the ultrasound, look at the backscatter and look at elastography and those kind of ultrasound parameters that can characterize soft tissue and then that's ah cannot be done with COVID-19. COVID-19 is really good for treatment planning, for implants, but once the implant is placed in terms of follow-up and you look at the mucositis emerging problem or parampatitis, ultrasound plays a ah huge role now because
00:16:35
Speaker
A lot of lesions happens first in the soft tissue before the bone is the victim of the inflammation or infection. And from our recent studies, we're already ah supported by the R21, the NIH R21 studies. We already see the the lesions in the soft tissue that are very obvious on the ultrasound, and that is not visible on the common CD. Because when you look at the bone,
00:17:05
Speaker
ah loss, that's a leg marker and that everything happens already and this sometimes it's too late. And on the other hand, when you look at ultrasound, it's just ongoing, it's happening and you can see that active lesion before the bone are resorbed and you can you can have a possible um subclinical diagnosis and then that can lead to early intervention.
00:17:34
Speaker
So those are the the beauties of the ultrasound really to complement convince DT and other radiographic i images. It's not totally replaced. I don't think we can ever replace radiology in dentistry. is It's a complement to each other. So that's that's a beauty.
Integrating Ultrasound into Dental Clinics and Insurance
00:17:54
Speaker
of Yeah. So when i when I teach residents ultrasound in radiology in the medical school, um i I always tell them that ultrasound is great, but ultrasound is not everything. And as ah as a radiologist, you need to make a decision on what is the most adequate imaging modality, be it nuclear medicine, CT, or x-ray, or or ah MR, or ultrasound. And if you have a concern about soft tissue, maybe ultrasound is your best modality that you have. If you want to know about heart tissue, maybe it would be x-ray or CT. ah The interesting part is that combim CT is, of course, ah inherently three-dimensional modality, which gives you beautiful images of the entire anatomy in 3D.
00:18:48
Speaker
But ultrasound is like a movie because it is real time. It has motion with it. And depending on what you need, one is better than the other. And the question is, which one? And that depends, as I said, on the individual situation. We haven't even talked about biomechanics yet. That is something that plays a big role in mastication.
00:19:10
Speaker
that right now there is no good imaging modality except for ultrasound available for dentists. And I can see that in the future, we will discover many great uses, um but we need to start with one, introduce it to the clinical field, and then work on more as people gain experience and find out what is adequate for ultrasound use and what is better done in x-ray or with combim CT.
00:19:38
Speaker
Very exciting. How long does it take? How long did it take you to evaluate your site? Um, yeah, it depends on what you want to look at. And in general, if you look at the phenotype, you look at anatomy. Um, and first, uh, it's a dynamic, it's a real time. So you, you basically put a probe where you, your focus, your region of interest is, and then you walk through like a missile distally and the change your direction a little bit. And then you identify, you need to have a clear.
00:20:15
Speaker
ah image in mind that what you want to look for. And then once you know that and you you look at the anatomic structures with the CJ or this input platform or the you know the soft tissue surface and the free general margin and the meco-general margin. And once you capture all the anatomy and you you record it, usually it takes, I think, less than five minutes and you should get quite good imaging.
00:20:49
Speaker
If you want to look at more details, you look at the raw image and you want to see the blood flow and that takes a couple more minutes to record it. So so those are the the amount of time that you will spend for recording, acquire and you can read the image right away too. So ah about, I would say most likely less than 10 minutes. And imagine you can see different tissue types.
00:21:17
Speaker
You can see the epithelium. You can see the red apex layer underneath. You can see the connective tissue. You can see blood vessels in there. You can see nerves. You can see muscles, tendons. That is something that really it does not exist right now in a cross-sectional way. And even if you have an X-ray or a cone beam CT,
00:21:39
Speaker
yeah it It just doesn't have contrast, ah let alone the the resolution. I mean, x-ray has great resolution. There's no doubt, but it's a projection image and it does not have contrast for soft tissue. ah But as we all know, it is unprecedented for heart tissue, for bones, crowns, roots. It's it's excellent. So again, it it really depends on what you what you need to know for your diagnosis.
00:22:07
Speaker
So you're really pioneers in ultrasound. Is anybody really looking with, let's say, insurance companies for finding a way to get reimbursed or getting a, maybe there is already a CDT code? Is there anything like that available already?
00:22:22
Speaker
Yeah. And that's a good point, Flavia. Actually, there is a CDK code already for ultrasound acquisition and interpretation. So that's ultrasound, the use for was from the oral surgery, I believe. They use a lot of, oral surgeons use a lot of ultrasound for diagnosis and for trauma planning and wind healing evaluation.
00:22:47
Speaker
I think that's how the CDT code was built for our surgeons, but now we can use.
Patient Acceptance and Training Standardization
00:22:54
Speaker
And the one of the biggest insurers, Delta Dental, is really interesting because it's non-invasive and non-radiation, and it's a good great soft tissue imaging.
00:23:06
Speaker
And we are working with the Delta Dental too, so that we can possibly find a ah you know the solution that really benefit our patients. At the end of the day, what we really want to achieve is to benefit our patients. And ultrasound is relatively low cost compared to COVID-Cd.
00:23:27
Speaker
and it's pretty much harmless. So yeah, so companies, insurance companies are looking at ways to reduce the radiation. So ultrasound on top of that coming as a primary tool for that purpose. And and there there's actually one extra benefit. There's very good patient acceptance. if If you tell a patient that we're gonna do another few X-rays,
00:23:56
Speaker
They might actually know that this is ionizing radiation ah and there might be some resistance. ah And if you say we're going to do a few more ultrasounds, nobody will ever complain about an ultrasound. Very, very exciting. So if somebody is interested in the ultrasound, it is available. They want to purchase it. How do they get trained? Because currently it's not available.
00:24:21
Speaker
in schools, not all schools teach that and most schools don't. So what would be the best way to learn how to use it, learn, or interpret it?
00:24:32
Speaker
um We are working with with groups that are becoming interested in the use of ultrasound, ah and we're providing training to to some of the groups. um But what we're looking at overall is a way that we can have our national organizations like the AAP and my organization, the American Institute of Ultrasound Medicine, AIUM, that they together offer our training. AIUM is already offering training, and one of our one of our colleagues at Ohio State ah was probably just the first one last week to actually get a certificate in the use of ultrasound.
00:25:14
Speaker
And ah we we look in ways of making this more available, that people can A, show up proficiency, they can learn how to use ultrasound, and then ultimately what we also need is ah programs that teach more in-depth use of ultrasound ah for research purposes.
00:25:36
Speaker
and Quantification of ultrasound on one side can be very easy, but it also has its caveats with it. And so we need to make sure that users know how to properly quantify images that they have recorded. All right. That's very, very exciting. I think making it available and making sure people get trained is is really important. and Elsie would like to bring up that we haven't discussed yet.
00:26:08
Speaker
I hope we find more people that are curious and that will engage this new technology. And I hope that we have an ongoing open discussion about its use. ah What but I hope for is that we have enough exchange to find all the positives of ultrasound and address any issues that come up ah before they um channel into something else.
00:26:38
Speaker
yeah Because when there's new technology, you always have to be careful. I think when the first travelers brought potatoes back from the United States or from the new continent, they didn't know that they had to be cooked. And so they crucified those those poor people. They didn't know. ah they They thought they would be poisoned with those potatoes when they were eating them raw. And then they figured, hey, you have to cook them first. And so with ultrasound, it is something that ah you need to know how it works.
00:27:08
Speaker
and then you can have a great experience. ah And it's ultrasound can make a big difference so ah for for for dentistry if we're using it right. I personally really miss ultrasound.
00:27:25
Speaker
ah Really, I really miss ultrasound photography for like, because whenever I'm curious, I just want to grab the ultrasound to see what is inside.
Enhancing Diagnosis and Treatment with Ultrasound
00:27:36
Speaker
But right now I don't have it, but I really missed it. So in so you have withdrawal system symptoms trust. So in what kind of procedures do you miss it or what kind of situations do you miss having the ultrasound available for you?
00:27:54
Speaker
especially implant, especially peri-implantitis, inflammation around implant and as well as to see after surgery, if the patient is swelling, I don't know what to do without ultrasound. Should I open and clean or should I wait and anti-biotic? So, ultrasound really drives my treatment plan.
00:28:22
Speaker
like What should I do? But right now I don't have a chance to have it. But in the future, maybe I really miss because it's really changed my patient treatment. Yeah, I think this will be a joint effort to advance the use of ultrasound. It's not only for research, but also from the industry and the interest if there's so many companies making the ultrasound devices and probes and to engage them and to show them the values and potential, the benefits so that they can chip in. And also the the education institutes, the training comes in and the partner with the
00:29:08
Speaker
the national organizations, especially the AAP and the the ultrasound organizations. And then the interest, the young generations, they're all about the technology savvy. And then they they're really open to new technology. I think this is the prime time for us to to advance the use of the ultrasound. So it's really exciting era now for us.
00:29:36
Speaker
I could see that you will see this mass effect that ah of of students that will ah react just like Benyatta. Once you use ultrasound to look into the gums and you're used to it and now suddenly somebody takes that away from you.
00:29:57
Speaker
people feel empty, they will feel helpless ah just because it is a new dimension. Imagine there would be no more x-ray or no more combim CT and you would have to guess if there is a cavity or if there is some kind of lesion in the heart tissue and you would have to just wait.
00:30:22
Speaker
ah that would be crazy ah because it's just so established it's not going to happen but ah it is a dimension that is taken away and if you don't know that dimension then you just don't you don't have a ah ah realization for it. And so it is it is opening a new avenue. And for that, ah we need to find good example uses of it and introduce those to the to the, again, to the specialties and then propagate from there to the general dentistry.
Interdisciplinary Collaboration for Successful Ultrasound Use
00:31:02
Speaker
We just want to provide the best patient care forever for our patients. We need we need to decide what's best for my patients and my students' patients. So until soon, we'll help them, if I have it.
00:31:21
Speaker
and and And for those that are ah worried about ultrasound, Albert was saying that it is actually not new. It is new in the dental schools, but it's not new in oral surgery.
00:31:39
Speaker
Oral surgery has used ultrasound. It says that the quality of ultrasound that they have or had is not as good as it could be. So you could, again, take this example of specialty and then general use. The specialty already uses it, i.e. oral surgery, but it wasn't good enough to find its way to a greater use, i.e. the the dental schools.
00:32:05
Speaker
And I think we're observing this shift right now. ah Because again, ultrasound is not new. What happened to make it more useful are two steps. One is the ultrasound probe that we have ah became smaller. So you can easily use it inside of the oral cavity and not just incisors or canines. And the frequency got higher. And a higher frequency translates with ultrasound to higher resolution.
00:32:33
Speaker
And so now we have a maximum ah resolution in the image of about 60 to 70 micrometers. And that is pretty high resolution compared to maybe comb beam CT if you push maybe 200 micron on a comb beam CT. Now, compared to an X-ray, it's still small, but it's not a projection image. It is a cross-sectional image.
00:32:55
Speaker
Okay, so um I think for ah for research purposes, certainly, and maybe even for initial clinical use, I would strongly recommend that groups work with ultrasound experts. ah this People like me that have been doing ultrasound for 30 years,
00:33:15
Speaker
um I know how ultrasound artifacts look like. I can spot them. I know how to quantify ultrasound images. um And so folks at different universities or institutions ah should find somebody ah that can guide them until we have a either a national or yeah maybe national program that offers adequate training materials.
00:33:44
Speaker
at various levels of of depth in terms of ultrasound. ah These can either be for for clinical use, for diagnosis, or they can be for research use ah that might span a much more detailed approach to ultrasound.
00:34:03
Speaker
ah Because when you develop new methodologies, then ah you face artifacts that you might not be aware of that are ah not covered ah by standard operating procedures or not covered by practice parameter guidelines. And that's what clinical procedures are. They follow a very specific path.
00:34:23
Speaker
And in research, you deviate from that path intentionally because you try to find new avenues. And so for those, we really rely on teams that are interdisciplinary. I would not be able to do this without Albert. And he might not be able to do this with me, though. Maybe he would find somebody else. ah But what i'm what I'm getting at is that we need to make sure that the teams have adequate expertise.
Concluding Reflections on Ultrasound Progress
00:34:52
Speaker
All right, excellent. I think there's been been very exciting, very enlightening. And I think we should be able to to see this in many practices in the future. I see a lot of advantages of using it. I mean, many advantages, actually many more than I thought there were out there. So I'd like to thank the three of you for spending this time with me. So thank you, Benyapa, Oliver, now for this wonderful opportunity to you know showcase a little bit of what you have been doing for the past 10 years.
00:35:22
Speaker
Thank you, Flavia. It's our pleasure. Thank you. Thank you for joining our episodes today. If you like this episode, share it with a friend. Don't forget to subscribe to the podcast wherever you're listening so you get the latest episodes.