Transcript
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. Hello everyone, I'm Dr. Effio Anidou and I'm the Editor-in-Chief of the Journal Periodontology and Clinical Advances in Periodontics.
Speaker: Tune with our team to Probing Perio, the podcast that aims to discuss advances and innovation in periodontology and implantology.
Speaker: Welcome to this special series of Probing Perio. Today we're going to explore innovations in microsurgery, the role of non-invasive blood perfusion imaging, a review and framework from the clinical advances in periodontics special issue, microsurgery and periodontology and implant dentistry. These articles bring together international experts who examine how magnification, precision instrumentation, advanced imaging, and refined surgical techniques are transforming periodontal and implant care.
Speaker: From historical perspectives and educational frameworks to innovative regenerative procedures and complex implant management, this issue highlights both the science and artistry of microsurgical practice.
Speaker: Whether you're an experienced microsurgeon, a clinician considering magnification enhanced techniques, or a student seeking to understand the future of periodontal and implant therapy, this collection offers valuable insights and practical guidance. So I'll now have our guests introduce themselves.
Speaker: Hello everyone, thank you for joining us. This is Albert Chen and currently at the Ohio State University and College of Dentistry. I'm currently chair the program.
Speaker: Nice to meet you. Hi, my name is Amanda Rodriguez and I'm at the University of Illinois Chicago College of Dentistry. I graduated as a periodontics resident and now I am doing a PhD in oral sciences.
Speaker: Hello, this is Oliver Kupfkens from the University of Michigan. I'm a physicist by training and I work in radiology and my background is ultrasound for medical and dental applications.
Speaker: It's a pleasure to be here. All right, welcome everyone. I'm Flavia Piri and I'm a co-editor of the Clinical Advances in Periodontics. So my first question to you guys is what clinical challenge or knowledge gap motivated this work?
Speaker: Yeah, thank you for this question. i I think we we all understand the wound stability and the blood perfusion are ah quite critical, especially for regenerative procedures.
Speaker: um We look at in the 70s, 80s studies and they use invasive ways and using injections, dyes and using fluorescence to look at blood flow. Beautiful work. However, it just very limited sample size and it's invasive. And currently, I don't believe we can do this um in the larger scale. That's kind of trigger how we we want to use a non-invasive and the chair time imaging and to understand how blood flow or perfusion changes after any surgical interventions, especially for regenerations.
Speaker: And with that information in mind, then we're then we were able to understand how the blood flow relate to the clinical outcome. So I think this is the ah critical step for us to ah finally have the tools that we are really desire for to look at the correlation between blood flow and clinical outcomes.
Speaker: Very nice. And what's the single most important message clinicians should take away from your paper? I think the single message could be perfusion links surgical execution to wound healing and microsurgery bridges that gap between perfusion and the outcome and the surgical execution. So for me, the question comes from a clinical perspective when I was in residency in which you look into literature, what type of incision and flap design you want to apply every time you do any type of procedure.
Speaker: And then there is no good answer to any questions because the clinical scenarios vary as you start doing more and more surgery. So looking at non-invasive technology just as ultrasound or laser speckle could provide that understanding preoperatively to tailor each incision design with some knowledge before the surgery, and then have a successful outcome. And that's why we see when we don't have these tools, different variability in the outcomes, even though we apply in the same incision and flap designs. So for me, it's very important to have this understanding prior so we can adapt to anatomy and perfusion and then have a better outcome outcome at the end.
Speaker: And since we're talking about microsurgery and new technology, what emerging trends are most likely to influence microsurgery over the next five to 10 years?
Speaker: If we look at the development of microscopic use in dentistry, It's no brainer that in the endo field that magnification certainly improve their ability, our endodontics colleagues to um to to be able to find ah canals like MB2s or accessory canals or um those kind of anatomical details. I mean, certainly perio can look into um detailed anatomies.
Speaker: And however, I think we we don't have strong evidence yet to show that, yes, we use the scopes and then that's a tool and also along with micro instruments. And how does that link to ah better biological reactions? And I think that's the the key missing point that we need to overcome before microsurgery, before we feel confident that microsurgery is helpful and then can make an impact in our field. Certainly there are some emerging evidences from Renaud-Bucard studies and split mouth designs, and they're showing that early perfusion is really, really um
Speaker: improved with the micro instruments, microscope compared to control. And that that also ah show later better root um And there then we we should we should have more evidence from a literature, from research. I think that's one of the the beautiful part of this initiative and also the framework is we kind of hypothesize what may have happened we use a microscope on wound healing and on blood perfusion. And then with those hypotheses, then we can we can eventually use the methodology to either approve it or refute it.
Speaker: as ah As a non-clinician, I'd like to interject here that I see the microscope as a tool to do a certain technique. And I see the ultrasound and laser speckle as tools to give ah objective and quantitative feedback. Ultimately, i could see that ah not every patient might need microsurgical intervention, but we the surgeon can be better informed at some point which subjects or which patients would benefit from microsurgery and then um have better decision making that way and also get follow-up and um I mean pre-op and post-op with with technology ultrasound laser speckle maybe others.
Speaker: Excellent. So correct me if I'm wrong, but this review identifies laser speckle contrast imaging and ultrasound as the two most promising modalities with laser speckle providing a broad superficial perfusion information and ultrasound adding deeper cross-sectional anatomy and vascular information. Is that correct?
Speaker: Yes. yeah So for the periodontist or for the dentist who has never seen laser speckle, what exactly are we looking for at at at the color perfusion mats? What exactly are they trying to identify? Yeah, um maybe I go for this one. um so These are two methods that are currently not used in the clinic. They're used in research, but clinicians don't necessarily know about them. One is based on optics, the other one is based on acoustics. ah Laser speckle is a methodology to use optics to look at the tissue
Speaker: and ah by what's called correlations, which are comparisons at high resolution, at at light resolution, um to see blood flow that is very superficial, typically within a few hundred micron of the tissue surface.
Speaker: It does that just like a photograph does over time, like a movie. And it identifies regions ah with which there is a lot of variation and it ah it attributes that to a lot of blood flow in those regions where it doesn't detect any change. Like for example, if you have a crown in the field of view, it will show up as a region that doesn't profuse at all, which makes sense. that Within a few hundred microns, there is no blood flow in ah in a crown.
Speaker: And so ah if you compare that to ultrasound, ultrasound is based on acoustics and it is a cross-sectional modality. So you'd see only a ah a line, so to say, of the surface as opposed to the laser speckle that shows the whole area as the surface, but it can look into the tissue. So if you have a gingiva or other soft tissue that is several millimeters thick, there's no problem for ultrasound to look into it. and display the content, ah that the structural content of the soft tissue, including blood flow, as well as the underlying heart tissue that might be present there, either bone, root, or a crown that is covered, or an implant that might actually not have bone covering it anymore, so only overlying soft tissue.
Speaker: And those are instrumentation that enhance what's currently possible for the clinicians. Excellent, excellent. So ultrasound is particularly exciting because it can simultaneously show our anatomy and vascularity. Could periodontal ultrasound eventually become as routine as a CBCT for certain indications?
Speaker: andm I'm going to start and I'll let my clinical colleagues continue. ah It is not the intent right now for ultrasound at all to replace anything but not using it. It does not replace Conebeam CT unless you do the Conebeam CT to see if an implant still has overlying bone or not. But cross-sectional imaging of heart tissues, including the crowns and roots and to certain degree implants, are but certainly bone, ultrasound is not in a position to do that.
Speaker: It has other functions that currently might require surgical intervention or guessing or very bad informed decisions based on cone beam CT and x-ray.
Speaker: um Ultrason is a very interesting tool because it provides you an idea of the underlying anatomy that you're seeing with your own eyes, right? So it makes us understand thickness of the gingiva, like if it's attached, if it's not attached. Also gives us an understanding of muscle attachment, frenum attachment. And I think that's very important because when we're looking with our eyes and we start doing our surgery, We can understand the basic anatomy, but there is variations. And then sometimes we miss some attachments of muscles, attachments of tissue around. So when we're doing anything regenerative, we're able to understand better these things that we miss with our bare eyes, right? Because we have a technology
Speaker: that is highly, ah pay attention to detail, right? But not only that, but the perfusion part um in the subclinical inflammation during healing and how much blood flow is coming to the wound. We know when when there is no flow in the edges of the wound, you might have an opening and then that leads you to inferior tissue loss and quality. So I think it's ah ver as a great technology to see before and during healing.
Speaker: and also the flow, because flow, it's kind of like what drives your surgery outcomes to my liking. Yeah, I guess it's more like a customized the medicine.
Speaker: And then from from the literature, we know everyone has a different distribution of the blood flow, especially superperiosteoplexis.
Speaker: That is the primary suppliers to the periodontion. And then with that in mind, we hypothesis that that's why we see difference in the outcomes because everyone's different and we have a standard way of making incisions, for example, crystal incisions and extend to adjacent teeth and some sort of vertical incisions if needed.
Speaker: that Then if we use the standard way doing um vasculature that is variable, then we'll get a variable outcomes.
Speaker: So the the technology, for example, ultrasound and laser speckle that really can map the the thatet microvasculature can be very helpful when we design our flap. And at the same time, we found it's very useful to monitor wound healing, especially at the early wound healing, the week or two. And from the preliminary data, we already see that some perfusion issues, maybe because of the surgical trauma or because the the wrong incisions or because of the tension in the flap and contribute to compromise the blood flow and in turn hurt our clinical outcome. so
Speaker: To be short, I believe that the initial screening and the flap design and also the monitoring the wound healing will be two big indications for for technology like ultrasound and the laser speckle.
Speaker: So since we're talking about the utilization of this technology, do you think perfusion could become another variable in surgical treatment planning, such as identifying defect morphology or keratinized tissue width, for example?
Speaker: Yeah, absolutely. I think perfusion drives um the beginning and the end of every procedure and it should be tailored. In a previous publication of our team, we hypothesized the collateral vascularization that we have whenever we are planning a procedure. And then we found that as Dr. Chan said, the superperiosal arteries are the ones that kind of help to heal. So it's basically collateral circulation. It doesn't have a big vessel coming up. And in previous studies, we have seen also that it goes apical coronally. And then the closer you get to the gingival margin, the less perfusion are.
Speaker: And then basically all of our procedures are based on how it reperfused at the coronal edges. So when we are doing any procedure, and specifically these hypotheses build and review, we observe that in the crestal area, there is very low perfusion compared to the more apical area. So we were able to kind of confirm what we initially thought about it, I hypothesized. So our goal is to provide the less surgical trauma and pre-servascular flow to get to that result, right? By minimal tension and then microsurgery help us to build and bridge that gap in general.
Speaker: So along those lines, do you think we we would eventually establish a perfusion threshold for example, to say, well, if we are below this threshold, we will have higher risks of wound dehiscence, graft exposure, perhaps not even perform the procedure. Yeah, I think that's ah that's the...
Speaker: um That's ideal situation. And then we also realize that in the, a lot of biomarker studies from tissue fluid and also even like a microbiology evaluations, i mean, each individual has a huge variations.
Speaker: So I guess we what we need to know is what is the average and more importantly, we need to know there' the the noise behind it.
Speaker: For example, like yours different from mine and how much difference is. And knowing that, that's why we we another the project we're doing now is to establish the baseline.
Speaker: value for a larger group of people. So we kind of understand what is what is normal. And then also we evaluate the cases over time and look at the normal, what is considered normal healing defined clinically.
Speaker: no inflammation, no infection, no wound opening, and see what is the normal projection of the blood flow. We know that during the inflammatory phase, we have increased blood flow, and after around one week, the blood flow should come down.
Speaker: And once we build the normal and then we can start to look at to set up the threshold and then define what is considered normal and to validate with the clinical outcomes and to see if that's that's true.
Speaker: I think that's that's a key aspect, Flavia, you point out. yeah and I think it also really highlights the importance of being very precise with our surgeries too, right? The less damaged, the better. i mean, we know that, but I think it just really highlights the importance of surgical skills and the importance of knowing where to design your incision and things like that. So if there's one thing that you would like periodontists or dentists to change in their surgical technique based on what we know about perfusion, what would that be?
Speaker: I'll go first and then again let let the clinicians chime in. ah what So i have I have two major research areas. One is oral ultrasound, the other one is blood flow quantification, but not not just oral, but in the general body, anywhere.
Speaker: and ah What I really appreciate is when ah physics and engineering meets biology. And, Flava, you were going that way, and then Albert was was pointing out the concept of biomarkers.
Speaker: what What we are missing the... the ah the ah the the merging of engineering and biology where we know that ah a certain amount of tissue, let's say 100 grams of tissue, and that would be maybe even way too much, but let's just say 100 grams of tissue needs x amount of oxygen per minute in order to be viable. And probably even more if it's doing additional function of wound healing. So if we know the amount of oxygen and then of course nutrition that is needed per time, If we would be in a position to use the blood flow form information as a volumetric flow, then we could actually figure out how would you make your flap design to warrant that you still have blood vessels that that can supply that amount of blood after the surgery,
Speaker: and or monitor after the surgery what is the blood flow looking at right now, does it improve, and is it at a magnitude that is actually suitable for full tissue regeneration? We're not there yet, but if if tomorrow would be my favorite birthday or something like this and I would have one wish, that would be great.
Speaker: Anything else you'd like to add? yeah Sure. So from from our point of view, is shed light on the biological mechanism of wound healing and realize that reperfusion drives the successful outcome and then work in our favor instead of against it. And then while using the microscope provides all the technical skills to provide less surgical trauma.
Speaker: And then that's kind of like the theoretical foundation that we're gonna have early tissue reperfusion. And then we shorten the inflammatory phase. which is the one that provides the work complications. And by that, we are improving our outcomes and then using ultrasound and laser speckle are just complementary tools to allow clinicians to see before, so preoperatively, and then monitor the result is results of our biological response after the procedures.
Speaker: Yeah, on Dr. Rodriguez's comments, I mean, all boil down to surgical trauma, the amount of surgical trauma. Whenever we do incision, flap reflection, and additional periosteal scoring, those kind of procedures that we we do more commonly for regenerative procedures, guided tissue regeneration or guided bone regeneration.
Speaker: or repair peri-infantitis lesions. And those becomes very important that we should ah induce minimal trauma to the tissue and reduce the tension whilst to achieve our goals. i think that's the I think that's the key information I would like to bring about. And that put the microscope as a a favorable position for achieving those goals.
Speaker: And so if listeners remember only one message from our discussion today about microsurgery and blood perfusion, what should that be? I would think that was the... Yeah, the connection. You have you preserve the blood flow through minimized surgical trauma and reduce the flat tension. And that is achieved with the microscope with ah cy associated with instruments.
Speaker: And we talk a we'll talk about techiles the technique skills and non-technic skills and all of these potentially contribute to better outcome.
Speaker: Anything else that I have not asked and you would like to add before we end our podcast? I would like to add what the listeners should remember, and that is The older I get, the more i appreciate the young generation that comes in that doesn't stick with old techniques, but is rethinking what is possible.
Speaker: And when I teach medical instrument systems, I always tell the students that there is no better between CT, MRI and ultrasound and and nuclear medicine methods. There's only something that tells us about the biology of the body. And so the the young folks that are coming in, all the old folks that are not too traditional, stuck in their mindset, always use what is the best for your question. And if it is ultrasound, try to use it. I know it's new. If you think laser speckle imaging is ah is a better methodology, then maybe that's the one.
Speaker: ah But don't stay stuck with the existing clinical traditional ah methods for diagnosis if there is something better out there. have one more thing.
Speaker: There to think and perform outside the box. So true. Yeah. Yeah. All right. Anything, Albert? No, I have nothing to add. i just want to thank everyone. Thanks for AAP and for for the invitation. All right. So ah very, very welcome. This is a very exciting paper. So thank you for joining us as we explore microsurgery and periodontology and implant therapy. And stay tuned for more upcoming episodes exploring other papers in this special issue.
Speaker: We hope we have encouraged you to dive deeper into this special issue of clinical advances in periodontics. Until next time.
Speaker: 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.
