Enhanced Visualization in Periodontal Therapy: A Clear Picture of Better Patient Care
Introduction

Periodontitis is a common chronic infectious-inflammatory condition.³ The primary etiology of periodontitis is dental plaque biofilm and bacterial-associated virulence factors.^4-6 These factors initiate a host immune response that results in the destruction of the hard and soft tissues supporting the teeth, this response is moderated by genetic, environmental, and acquired risk factors.^4-6 Initial periodontal treatment focuses on the effective and regular removal of the dental plaque biofilm and any secondary plaque retentive factors, such as dental calculus as well as host modulation and risk reduction strategies for periodontal disease modifying factors.^4-6 Adequate removal of primary etiologic factors is critical to achieving optimal periodontal health.^4-9 The long-term outcome of periodontal therapy, both nonsurgical and surgical, relies upon removal of the biofilm and elimination of periodontal pathogens associated with the tooth surfaces, periodontal tissues, mucosal surfaces, the tongue dorsum, and other niches within the oral cavity as well as the prevention of re-infection by exogenous and endogenous pathogens.^4,6 Nonsurgical periodontal therapy aims to establish a root surface that is biologically acceptable for the reestablishment of a healthy periodontal attachment,^10-13 but this can be a challenge in areas where visualization cannot be reliably achieved and access for debridement is limited. These areas may include deep periodontal pockets, root flutes, root concavities or other anatomic limitations, and the cemento-enamel junction (CEJ).^14-17 It is well-established that surgical flap reflection to allow for enhanced visualization improves the efficacy of root surface debridement and may account for improved clinical outcomes after surgical treatment at some sites.¹⁸ While surgical debridement may improve biofilm and calculus removal, there are limitations and adverse outcomes of periodontal surgery in some instances. Increased gingival recession and esthetic compromise as well as post-operative discomfort and dentinal hypersensitivity (DH) are all common sequelae after periodontal surgery.¹⁹ To reduce morbidity associated with surgical interventions and improve the outcomes of nonsurgical periodontal therapy many therapies have been proposed for use in practice, including the use of laser-assisted periodontal debridement, subgingival irrigations, local delivery of antimicrobial therapies, and enhanced visualization techniques. Specifically, enhanced visualization techniques, including the use of loupe magnification, microscopy, and periodontal endoscopy have been proposed as methods to avoid or limit surgical access in certain clinical scenarios. In addition, surgical techniques may be employed to repair defects caused by periodontal disease progression and acquired or innate mucogingival deformities. This course will review the adjunctive use of enhanced visualization protocols during the treatment of periodontal diseases and conditions.